Ethel Leonor Noia Maciel1
The World Health Organization’s (WHO) “End TB” strategy has highly ambitious targets to reduce TB deaths and new cases by 95 and 90%, respectively, by 2035 compared to 2015, and to ensure that no family is burdened with catastrophic expenses due to TB. The strategy is based on three pillars 1 :
integrated, patient-centered care and prevention; bold policies and integrated information systems, including social protection for patients and recommendations for universal health coverage; intensified and innovative research and inclusion of new technologies.
integrated, patient-centered care and prevention;
bold policies and integrated information systems, including social protection for patients and recommendations for universal health coverage;
intensified and innovative research and inclusion of new technologies.
In BRICS countries, such as Brazil, the current strategies are not focused on achieving these goals, since the efforts have led to a modest reduction of 2% per year over the last decade 2 . To meet the targets proposed by WHO, the rate must decrease 10% per year over the next 20 years - an enormous challenge.
Brazil has a TB cure rate of 55% among people living with HIV (PLWH). It still has room for improvement in the pillar one (Integrated, patient-centered care and prevention) strategy 2 . Likewise, preventive therapy for latent infection is vastly underutilized in this high-risk population 3 . Currently, the primary focus of Brazilian TB control program is on diagnosis and treatment of active disease, with few actions in contact investigations and preventive therapy activities 4 , although since 1995 5 WHO and Brazil have guidelines 3 calling for these strategies. WHO guidelines on preventive therapy 3 emphasize the need to increase rates of initiation and completion of Latent Tuberculosis Infection (LTBI) treatment, mainly in groups of higher risk of progression to TB, such as PLWH.
Based upon local 6 and global evidence 7 , Brazilian guidelines 4 recommend Isoniazid Preventive Therapy (IPT) for at least six months using a dose of 300 mg/day. Recently, there seems to be, at last, a new guideline and a more effective and efficient strategy. The AIDS program assumed responsibility for IPT, as they have done related to the prevention of other diseases, and the treatment for LTBI is now recommended for all HIV patients with a CD4 count equal to or below 350 - regardless of whether the Tuberculin Test (TT) was performed or not, since active tuberculosis was excluded 8 . The good news is a new presentation of the drug Isoniazid, in a single tablet of 300mg. A study has been conducted by Universidade Federal do Espírito Santo, funded by Ministry of Health, to evaluate the adherence and adverse effects of this new presentation, but the latter is already available for PLWH.
Furthermore, there is a new surveillance system for notification and monitoring of cases of latent TB, but still not for the whole country, and an indicator to address specifically preventive therapy is not clear yet. So, these are indeed good news to celebrate.
If Brazil added a preventive therapy indicator, it would be the new target to be met. Hence, it would result in innovative strategies to reach this goal. Moreover, with an integrated surveillance system, both, AIDS and TB programs would be able to monitor LTBI treatment more effectively.
Finally, TB and AIDS programs should definitely work together to control TB in PLWH, since one target is not achievable without the other across the whole country.
The authors declare there are no grants or other funding for all authors.
ETHEL LEONOR MACIEL. Laboratory of Epidemiology, Universidade Federal do Espírito Santo. Avenida Marechal Campos, 1.468 - Maruípe. Vitória (ES), Brazil. E-mail: email@example.com