TB Preventive Treatment for People With HIV Through PEPFAR, 36 Countries, 2016–2023

Tuberculosis (TB) is the leading cause of death among people with HIV: about 167,000 died of TB-related causes in 2022. TB preventive treatment (TPT), taken with antiretroviral treatment (ART), lowers the risk of TB disease and TB deaths, and is recommended for people with HIV once active TB is ruled out — even if their latent TB status is unknown. It was long isoniazid daily for 6 or 9 months; shorter 1- and 3-month rifapentine regimens now exist.

At the 2018 United Nations High-Level Meeting on TB, countries agreed to give TPT to 6 million people with HIV by 2022. The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) committed to offer at least one course to every eligible ART client — pregnant women included — in programs serving about 19 million people with HIV.

How progress was measured

PEPFAR's reporting data, every 6 months, by age (under 15, 15 and over), sex, and HIV treatment status — ART-naive (on ART under 6 months) or ART-experienced:

• initiation rate: TPT starts in a 6-month period ÷ people on ART at its end;
• completion rate: TPT completions ÷ starts in the previous period.

U.S. fiscal years run October–September.

Results, fiscal years 2017–2023

• Countries reporting TPT data rose from 17 (FY17) to 36 (FY21).
• 16,832,651 TPT starts were reported. Starts grew about 26% every six months through FY19, dipped 12% in FY20 Q2, then rose to a record 1,802,814 in FY21 Q4, and have since declined.
• The initiation rate among all ART clients was 4%–6% in FY17–18, peaked at 11% in FY19 Q4, and fell to 5% by FY23 Q2 — possibly a sign of saturation, with most eligible clients already treated.
• Among ART-naive clients it rose from 17% (FY18 Q4) to 59% (FY22 Q4), then 53%.
• 13,323,186 people with HIV completed TPT. Completion rose from 56% (FY18 Q2) to 87% (FY23 Q2), then 86%.

TPT completions among people on antiretroviral treatment in 36 PEPFAR-supported countries, October 2016–September 2023. Figure from CDC's report.

Differences: overall initiation and completion didn't differ by sex or age. But among ART-naive clients, children under 15 started less often (32% vs 51%), and ART-naive clients completed less often than experienced ones (79% vs 86%).

TPT initiation and completion rates by age, sex and HIV treatment status. Figure from CDC's report.

What it means

TPT is now part of standard HIV care in PEPFAR-supported programs, and the 13 million completions contributed meaningfully to the 2018 UN target for people with HIV — the only UN High-Level Meeting target met. Newly treated people may face stigma, pill burden, less health education and long distances to clinics, which can lower completion.

Next steps:

• support every newly treated client to start and finish TPT;
• patient-level electronic records to find underserved areas and groups;
• patient-centered care that fits people's needs;
• short-course regimens for all, and child-friendly formulations;
• digital adherence tools — phone apps, sensor pill boxes;
• studies of whether TPT has cut TB cases and deaths, and extending lessons to others at risk, such as household contacts of people with TB.

Limits

• Programs are diverse, and the number of countries changed over time, so pooled trends may not fit any one country and aren't a true cohort.
• Completion is often based on pills dispensed and self-report, so it may be overestimated.
• Program data aren't as precise as research data, and there were no person-level data or finer age groups.

Sources

Based on Ajiboye AS, O'Connor S, Smith JP, et al., "Tuberculosis Preventive Treatment Update — U.S. President's Emergency Plan for AIDS Relief, 36 Countries, 2016–2023," MMWR Morbidity and Mortality Weekly Report, volume 73, Centers for Disease Control and Prevention; a work of the United States government in the public domain.