Design of regimens for treating tuberculosis in patients with HIV infection, with particular reference to sub-Saharan Africa

The highest burden of human immunodeficiency virus (HIV) related tuberculosis (TB) is in sub-Saharan Africa. HIV complicates several areas of TB control, one of which involves treatment and treatment outcome. Large patient numbers cause congestion on TB wards, there is increased morbidity, an increased risk of adverse drug reactions, an increased case fatality, and an increased recurrence of TB after treatment completion. TB Control Programmes have responded to these problems by taking actions such as abolishing thioacetazone and decentralising the initial phase of treatment to peripheral health centres and the community. Despite this response, there are three major on-going concerns which need to be addressed by research studies. There is a need to reduce case fatality rates focusing on 1) stronger treatment regimens, 2) adequacy of rifampicin levels when intermittent treatment regimens are used, and 3) adjunctive treatments. There is a need to reduce recurrent rates of TB by 1) determining the relative role of re-infection and reactivation as a cause of recurrence, 2) assessing the importance of duration and type of anti-TB treatment for the first episode of TB, and 3) determining the role of secondary isoniazid preventive therapy. There is a need to evaluate how best to decentralise treatment from the perspective of the health service and the patient. Research studies should be relevant to the needs and resources of TB control programmes, and should include pharmacokinetic studies, controlled clinical trials and operational research, including economic analysis and social science evaluation.