Systematic review of TST responses in people living with HIV in under-resourced settings: implications for isoniazid preventive therapy

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dc.contributor.authorKerkhoff, Andrew Den_ZA
dc.contributor.authorKranzer, Katharinaen_ZA
dc.contributor.authorSamandari, Tarazen_ZA
dc.contributor.authorNakiyingi-Miiro, Jessicaen_ZA
dc.contributor.authorWhalen, Christopher Cen_ZA
dc.contributor.authorHarries, Anthony Den_ZA
dc.contributor.authorLawn, Stephen Den_ZA
dc.date.accessioned2015-11-23T12:28:32Z
dc.date.available2015-11-23T12:28:32Z
dc.date.issued2012en_ZA
dc.description.abstractBACKGROUND: People living with HIV (PLWH) who have positive tuberculin skin tests (TST) benefit from isoniazid preventive therapy (IPT) whereas those testing TST-negative do not. Revised World Health Organization guidelines explicitly state that assessment of TST is not a requirement for initiation of IPT. However, it is not known what proportions of patients will benefit from IPT if implemented without targeting according to TST status. We therefore determined the proportions of PLWH who test TST-positive. METHODOLOGY/PRINCIPAL FINDINGS: We systematically reviewed the literature published between January 1990 and February 2012 to determine the proportions of patients without active tuberculosis attending HIV care services in low and middle-income countries who tested TST-positive (≥5 mm induration). Proportions were also determined for different CD4 count strata. Data from 19 studies with 9,478 PLWH from sub-Saharan Africa, Asia and Central and South America were summarized. The vast majority were not receiving antiretroviral therapy (ART). A sub-analysis was conducted of 5 studies (5,567 subjects) from high TB prevalence countries of PLWH with negative TB screens attending HIV care and treatment settings for whom CD4 stratified data were available. The median proportion of PLWH testing TST-positive overall was 22.8% (range, 19.5-32.6%). The median (range) proportions with CD4 cell counts of <200, 200-499 or ≥500 cells/µL who tested positive were 12.4% (8.2-15.3%), 28.4% (20.1-36.9%) and 37.4% (31.3-56.3%), respectively. Heterogeneity in the data precluded calculation of pooled summary estimates. Conclusions/Significance In most settings, if IPT is administered to PLWH pre-ART without assessment of TST status, only a minority of those treated are likely to benefit, especially among those with the lowest CD4 cell counts. This may be inefficient use of resources and cost-effectiveness analyses should take this into account. Local knowledge of TST response rates may help inform policies. New simple means of identifying those who will benefit from IPT are needed to permit appropriate targeting of this intervention.en_ZA
dc.identifier.apacitationKerkhoff, A. D., Kranzer, K., Samandari, T., Nakiyingi-Miiro, J., Whalen, C. C., Harries, A. D., & Lawn, S. D. (2012). Systematic review of TST responses in people living with HIV in under-resourced settings: implications for isoniazid preventive therapy. <i>PLoS One</i>, http://hdl.handle.net/11427/15291en_ZA
dc.identifier.chicagocitationKerkhoff, Andrew D, Katharina Kranzer, Taraz Samandari, Jessica Nakiyingi-Miiro, Christopher C Whalen, Anthony D Harries, and Stephen D Lawn "Systematic review of TST responses in people living with HIV in under-resourced settings: implications for isoniazid preventive therapy." <i>PLoS One</i> (2012) http://hdl.handle.net/11427/15291en_ZA
dc.identifier.citationKerkhoff, A. D., Kranzer, K., Samandari, T., Nakiyingi-Miiro, J., Whalen, C. C., Harries, A. D., & Lawn, S. D. (2011). Systematic review of TST responses in people living with HIV in under-resourced settings: implications for isoniazid preventive therapy. PloS one, 7(11), e49928. doi:10.1371/journal.pone.0049928en_ZA
dc.identifier.ris TY - Journal Article AU - Kerkhoff, Andrew D AU - Kranzer, Katharina AU - Samandari, Taraz AU - Nakiyingi-Miiro, Jessica AU - Whalen, Christopher C AU - Harries, Anthony D AU - Lawn, Stephen D AB - BACKGROUND: People living with HIV (PLWH) who have positive tuberculin skin tests (TST) benefit from isoniazid preventive therapy (IPT) whereas those testing TST-negative do not. Revised World Health Organization guidelines explicitly state that assessment of TST is not a requirement for initiation of IPT. However, it is not known what proportions of patients will benefit from IPT if implemented without targeting according to TST status. We therefore determined the proportions of PLWH who test TST-positive. METHODOLOGY/PRINCIPAL FINDINGS: We systematically reviewed the literature published between January 1990 and February 2012 to determine the proportions of patients without active tuberculosis attending HIV care services in low and middle-income countries who tested TST-positive (≥5 mm induration). Proportions were also determined for different CD4 count strata. Data from 19 studies with 9,478 PLWH from sub-Saharan Africa, Asia and Central and South America were summarized. The vast majority were not receiving antiretroviral therapy (ART). A sub-analysis was conducted of 5 studies (5,567 subjects) from high TB prevalence countries of PLWH with negative TB screens attending HIV care and treatment settings for whom CD4 stratified data were available. The median proportion of PLWH testing TST-positive overall was 22.8% (range, 19.5-32.6%). The median (range) proportions with CD4 cell counts of <200, 200-499 or ≥500 cells/µL who tested positive were 12.4% (8.2-15.3%), 28.4% (20.1-36.9%) and 37.4% (31.3-56.3%), respectively. Heterogeneity in the data precluded calculation of pooled summary estimates. Conclusions/Significance In most settings, if IPT is administered to PLWH pre-ART without assessment of TST status, only a minority of those treated are likely to benefit, especially among those with the lowest CD4 cell counts. This may be inefficient use of resources and cost-effectiveness analyses should take this into account. Local knowledge of TST response rates may help inform policies. New simple means of identifying those who will benefit from IPT are needed to permit appropriate targeting of this intervention. DA - 2012 DB - OpenUCT DO - 10.1371/journal.pone.0049928 DP - University of Cape Town J1 - PLoS One LK - https://open.uct.ac.za PB - University of Cape Town PY - 2012 T1 - Systematic review of TST responses in people living with HIV in under-resourced settings: implications for isoniazid preventive therapy TI - Systematic review of TST responses in people living with HIV in under-resourced settings: implications for isoniazid preventive therapy UR - http://hdl.handle.net/11427/15291 ER - en_ZA
dc.identifier.urihttp://hdl.handle.net/11427/15291
dc.identifier.urihttp://dx.doi.org/10.1371/journal.pone.0049928
dc.identifier.vancouvercitationKerkhoff AD, Kranzer K, Samandari T, Nakiyingi-Miiro J, Whalen CC, Harries AD, et al. Systematic review of TST responses in people living with HIV in under-resourced settings: implications for isoniazid preventive therapy. PLoS One. 2012; http://hdl.handle.net/11427/15291.en_ZA
dc.language.isoengen_ZA
dc.publisherPublic Library of Scienceen_ZA
dc.publisher.departmentDesmond Tutu HIV Centreen_ZA
dc.publisher.facultyFaculty of Health Sciencesen_ZA
dc.publisher.institutionUniversity of Cape Town
dc.rightsThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.en_ZA
dc.rights.holder© 2012 Kerkhoff et alen_ZA
dc.rights.urihttp://creativecommons.org/licenses/by/4.0en_ZA
dc.sourcePLoS Oneen_ZA
dc.source.urihttp://journals.plos.org/plosoneen_ZA
dc.subject.otherHIVen_ZA
dc.subject.otherTuberculosisen_ZA
dc.subject.otherMeta-analysisen_ZA
dc.subject.otherHIV clinical manifestationsen_ZA
dc.subject.otherSputumen_ZA
dc.subject.otherIsoniaziden_ZA
dc.subject.otherCost-effectiveness analysisen_ZA
dc.subject.otherAntiretroviral therapyen_ZA
dc.titleSystematic review of TST responses in people living with HIV in under-resourced settings: implications for isoniazid preventive therapyen_ZA
dc.typeJournal Articleen_ZA
uct.type.filetypeText
uct.type.filetypeImage
uct.type.publicationResearchen_ZA
uct.type.resourceArticleen_ZA
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