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How to manage patients who defualt from INH prophylaxis
Oct 6, 2010

If a patient on INH prophylactic therapy defualts from the treatment from treatment for some time like a month, what do we do for such clients which are becoming significant in era of universal IPT for all eligible? It is a global public health hazard?

Response from Dr. Young

Hello and thank you for your provocative question.

You're correct tuberculosis is a very significant health treat for persons living with HIV. This is particularly true for communities in Africa, Asia and Eastern Europe. Here in the US, screening for tuberculosis exposure is recommended by national treatment guidelines. INH preventive therapy is recommended for HIV-infected persons who have evidence of latent tuberculosis infection (by definition, without evidence of active disease).

The US Department of Health and Human Service HIV Guidelines state: "HIV-infected individuals found to have latent TB infection (LTBI), defined as >5 mm skin test induration or positive IGRA with no prior treatment for LTBI and after appropriate evaluation to rule out active TB disease and no prior treatment of LTBI, should commence treatment with isoniazid (with pyridoxine) for 6 to 9 months."

IPT and treatment for LTBI is of particular challenge to the parts of the world where LTBI is very common, or in persons with immune suppression (i.e., AIDS), because TB disease can often not include the typical lung involvement.

The interesting part of your question has to do with persons who discontinue their treatment. Understanding the notion that IPT isn't not an absolute method to prevent TB reactivation, but rather a strategy that decreases the likelihood of reactivation (and subsequent transmission), and keeping with the notion of patient self-determination, I don't think that IPT should be a statutory requirement for any individual patient. Rather, IPT should be offered (and if needed, re-offered) to at-risk, eligible persons. For those who decline treatment, a harm-reduction philosophy of continuing to engage patients in ongoing care and health monitoring can still decrease the risk of reactivation of tuberculosis or early treatment if necessary.

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