Reducing deaths from tuberculosis in antiretroviral treatment programmes in sub-Saharan Africa.

Mortality rates are high in antiretroviral therapy (ART) programmes in sub-Saharan Africa, especially during the first few months of treatment. Tuberculosis (TB) has been identified as a major underlying cause. Under routine programme conditions, between 5 and 40% of adult patients enrolling in ART services have a baseline diagnosis of TB. There is also a high TB incidence during the first few months of ART (much of which is prevalent disease missed by baseline screening) and long-term rates remain several-folds higher than background. We identify three groups of patients entering ART programmes for which different interventions are required to reduce TB-related deaths. First, diagnostic screening is needed in patients who have undiagnosed active TB so that timely anti-TB treatment can be started. This may be greatly facilitated by new diagnostic assays such as the Xpert MTB/RIF assay. Second, patients with a diagnosis of active TB need optimized case management, which includes early initiation of ART (with timing now defined by randomized controlled trials), trimethoprim-sulphamethoxazole prophylaxis and treatment of comorbidity. Third, all remaining patients who are TB-free at enrolment have high ongoing risk of developing TB and require preventive interventions, including optimized immune recovery (with ART ideally started early in the course of HIV infection), isoniazid preventive therapy and infection control to reduce infection risk. Further specific measures are needed to address multidrug-resistant TB (MDR-TB). Finally, scale-up of all these interventions requires nationally and locally tailored models of care that are patient-centred and provide integrated healthcare delivery for TB, HIV and other comorbidities.