What is the best way to reduce the death rate among HIV-positive people receiving treatment for tuberculosis (TB)? Based on results from Côte d’Ivoire, WHO/UNAIDS recommend the antibiotic, co-trimoxazole, for all African patients with AIDS. But will this work in Malawi, which has different patterns of resistance to this class of drugs?

In Malawi, at least 20 to 30 per cent of HIV-infected patients with active TB die within a year of starting treatment. Many of these deaths are due to infections. Could they be prevented by antibiotics? Research by Médecins Sans Frontières and Malawi’s National TB Programme aimed to:

• study the feasibility of introducing voluntary counselling and HIV testing (VCT) into the TB control programme
• assess the safety of using a cheap and widely available oral antibiotic called co-trimoxazole
• measure death rates among patients offered VCT and, if HIV-positive, given co-trimoxazole (test group)
• compare these results with rates in a previous group of patients who were not offered this package (controls).

The study involved nearly 2 000 TB patients in Thyolo District, southern Malawi. Key results include:

• 77 per cent of TB patients are HIV-positive.
• Two per cent of people have minor reversible skin reactions while taking co-trimoxazole.
• Compared with controls, the risk of death is 25 per cent lower in the test group. Treatment success is also better.
• These effects are seen mainly in new patients and those without detectable TB organisms (smear-negative), rather than those with smear-positive TB.
• One death is prevented for every 12.5 TB patients receiving the package of VCT and co-trimoxazole.

The study shows that this approach can work under routine programme conditions in a rural district in Malawi. Good links between hospital counselling services and community care groups are crucial to its success. Although a package of VCT and co-trimoxazole prevents one TB death out of every four, the overall death rates in the test group are still unacceptably high. The researchers recommend exploring other strategies to reduce early mortality, such as improving access to care, or to increase overall survival, in particular the provision of anti-retroviral drugs.

Should Malawi scale up this package across the country? Policy-makers will need to weigh up issues such as:

• the possibility of preventing over 2 000 TB related deaths countrywide each year
• potential reductions in HIV transmission due to behaviour change following VCT
• development of resistance to similar drugs used to treat malaria and childhood acute respiratory infections
• the provision of blanket co-trimoxazole without VCT to all TB patients if implementation of VCT is slow
• the option of giving co-trimoxazole only to those patients with smear-negative TB
• allocation of responsibility for drug administration, adherence and costs.

Source(s):
‘Voluntary counselling, HIV testing and adjunctive cotrimoxazole reduces mortality in tuberculosis patients in Thyolo, Malawi’, AIDS 17: 1053-1061, by A. Harries et al, 2003
'Tuberculosis case fatality rates in high HIV prevalence populations in sub-Saharan Africa', AIDS 15: 143-152, by Y.D. Mukadi et al, 2001
'High early mortality in tuberculosis patients in Malawi', International Journal of Tuberculosis and Lung Disease 5: 1000-1005, by A.D. Harries et al, 2001

Funded by: Médecins Sans Frontières – Luxembourg; UK Department for International Development; Norwegian Agency for Technical Assistance; Royal Netherlands TB Association

id21 Research Highlight: 4 November 2003

Further Information:
Anthony D. Harries
National TB Control Programme of Malawi
Community Health Sciences Unit
Lilongwe
Malawi

Tel: +265 1 754 936
Fax: +256 1 772 657
Contact the contributor: adharries@malawi.net

Medecins sans Frontieres

Rony Zachariah
Médecins Sans Frontières (Brussels Operational Centre)
Medical Department (Operational Research)
70 rue de Gasperich
L-1617
Gasperich
Luxembourg

Tel: +352 332 515 / +32 2474 7474  
Fax: +352 335 133
Contact the contributor: zachariah@internet.lu

LEPRA, UK

Other related links:
'What the patient ordered - meeting the needs of TB patients' >

'Airing the evidence: causes of lung disease in Zambian children' >

'Cause for pause – why patients put off seeking TB treatment' >

'Occupational hazard – protecting healthworkers from TB in Malawi' >

See id21's collection of links relevant to infectious diseases.

See id21's collection of links relevant to HIV/AIDS.