Tuberculosis (TB) is a major cause of death and illness among HIV positive children. However, medical experts are divided on whether to provide all HIV infected children with a preventive TB therapy using a drug called Isoniazid. (Isoniazid is a drug used to treat TB but has been found to provide protection from TB infection for HIV positive people).
The issue was a motion of debate at the 6th National Paediatric HIV/AIDs Conference held in Kampala from September 12-14.
Presenting recommendations for preventive treatment of TB among HIV positive children, Dr. Frank Mugabe the Ministry of Health Assistant Program Manager National TB and Leprosy Program told participants that Isoniazid Prophylaxis for Tuberculosis (IPT) reduces the burden of TB, the number of HIV/TB co-infected patients and reduces transmission of TB.
He pointed out that many people had not appreciated the importance of TB in the community yet Uganda is one of the 22 countries in the world with a high TB burden.
Globally there are about 9million people with TB in the world one million of which are children. There are two million TB deaths 250,000 of which are children.
Dr. Mugabe said there weren’t enough interventions for HIV-infected children yet timely IPT prevented TB-related deaths associated with HIV.
“The plight of HIV positive children with TB in Uganda should be looked into because the relationship is similar to that of adults and HIV,” he said.
“You are playing with a time-bomb. This bomb is TB. We’ll be in a problem. Once TB becomes a country problem, it will not be segregative,” he said.
Putting up a spirited presentation for the pros of providing IPT to HIV infected children, Prof. Philippa Musoke, a consultant pediatrician said 65% of healthy children exposed to TB bacteria get infected. 85% of these will clear while 15% progress to disease. However in HIV co-infected children, up to 50% of exposed children will end up developing the disease.
She presented several studies that have shown significant positive outcomes for use of Isoniazid among the HIV infected.
She quoted a South African randomized study in which the drug was given to children under two years old in a high prevalence TB area while the control group was given a placebo. The drug reduced death among the HIV infected children’s group that received it by 46% and TB incidence by 70%.
Another study in South Africa also among untreated HIV positive children showed that Isoniazid improved survival of the children who received it.
Dr. Musoke also highlighted other benefits: The drug prevents severe TB complications among children like TB meningitis, a very difficult and expensive condition to treat. It would also prevent TB of the spine which causes children to develop bent backs and deformed limbs – conditions that are difficult to treat once they occur.
WHO has made some recommendations on the use of the drug for countries to consider: That all children exposed to TB through the household contacts should begin IPT (Isoniazid Preventive Therapy) even when they do not show evidence of having the disease.
That HIV positive children 12 months and older receive 6 months of the therapy irrespective of TB exposure as part of the HIV comprehensive care package. Children under one year should not receive the therapy.
However, Dr. Eric Wobudeya, another pediatrician in charge of the pediatric TB clinic at Mulago hospital had reservations on the proposal.
Wobudeya said most of the recommendations were not based on strong scientific evidence.
He pointed out that WHO counsels that these recommendations be “carefully considered in the context of the local setting”. He said the Ugandan context was not a conducive environment to adopt the policy to implement IPT.
“We don’t have adequate advocacy, communication and social mobilisation on TB. We don’t have sufficient information environment to handle IPT. How many health workers are sensitised and trained on TB handling. We are not ready now,” he said. He also pointed out that the HIV and TB programs were not yet linked and that a good TB control program needed a system that guarantees reporting of completion of regimens for TB but tools were not adequate and some were still being developed yet a good monitoring system was necessary for TB care.
Dr. Sabrina Bakeera Kitaka emphasised the importance of educating and sensitising the population on TB management. “There are so many myths out there which are endangering the children born to mothers with TB,” she said.
Other practitioners wondered whether they could be assured of a regular flow of drugs for children, while others pointed out it was cheaper to prevent than treat children with TB.
Some were concerned about side effects, however, Dr. Musoke clarified that children did not get similar side effects from the drug as adults.