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Short-Course Prophylaxis against Tuberculosis in HIV-Infected Persons: A Decision and Cost-Effectiveness Analysis

David N. Rose, MD
[+] Article and Author Information

From Long Island Jewish Medical Center, New Hyde Park, New York, and Albert Einstein College of Medicine, Bronx, New York. For the current author address, see end of text. Requests for Reprints: David N. Rose, MD, Division of General Internal Medicine and Primary Care, Long Island Jewish Medical Center, 410 Lakeville Road, Suite 105, New Hyde Park, NY 11042.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1998;129(10):779-786. doi:10.7326/0003-4819-129-10-199811150-00005
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Background: Isoniazid prophylaxis for 12 months effectively prevents tuberculosis in HIV-infected persons and may decrease the incidence of other HIV-related disease and mortality. Recent clinical trials have found that some short-course regimens also effectively prevent tuberculosis.

Objective: To compare the benefits, risks, and cost-effectiveness of isoniazid prophylaxis and short-course prophylaxis regimens.

Design: Decision and cost-effectiveness analysis.

Setting: United States.

Patients: Hypothetical patients who are HIV-infected and have CD4 counts of 200 cells/mm3 or less and positive results on tuberculin skin tests.

Interventions: Isoniazid prophylaxis lasting 12 months and six short-course prophylaxis regimens of isoniazid, rifampin, and pyrazinamide alone or in combination.

Measurements: 5-year survival rate, life expectancy, life-time incidence of tuberculosis, and cost per quality-adjusted life-year saved.

Results: Compared with no prophylaxis, the 12-month isoniazid regimen increased 5-year survival rates by 9% and life expectancy by 8.7 months, decreased incidence of tuberculosis by 27%, and saved 4 medical care dollars for every 1 spent on prophylaxis. Regimens of isoniazid for 6 months, isoniazid and rifampin for 3 months, and rifampin and pyrazinamide for 2 months had similar results: 6.2- to 8.6-month increases in life expectancy, 19% to 26% reductions in incidence of tuberculosis, and 1 to 7 medical care dollars saved for every 1 spent on prophylaxis. A 3-month regimen of isoniazid, rifampin, and pyrazinamide resulted in fewer clinical benefits and was the only regimen tested that did not save medical care dollars.

Conclusions: Prophylaxis decreases the incidence of tuberculosis and increases life expectancy for HIV-infected patients. Some regimens save medical care dollars, and some short-course regimens have clinical and economic benefits similar to those of the 12-month isoniazid regimen. Short-course prophylaxis is a reasonable alternative to the 12-month isoniazid regimen.

Figures

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Figure 1.
Decision tree for HIV-infected tuberculin reactors.

The square represents a decision node; circles represent chance nodes. AE = adverse event; TB = tuberculosis.

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Figure 2.
Costs and benefits of prophylaxis compared with no prophylaxis.

All future costs and health events are discounted at a rate of 3% per year. The black circle represents isoniazid daily for 12 months; the white circle represents isoniazid daily for 6 months; the black square represents isoniazid twice weekly for 6 months; the white square represents isoniazid and rifampin daily for 3 months; the black triangle represents isoniazid, rifampin, and pyrazinamide daily for 3 months; the white triangle represents rifampin and pyrazinamide twice weekly for 2 months; and the diamond represents rifampin and pyrazinamide daily for 2 months.

Grahic Jump Location

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