Preventive medicine for HIV-infected patients

Objective:To analyze the policies of isoniazid prophylaxis for human immunodeficiency virus (HIV)-infected tuberculin reactors and for HIV-infected anergic patients with unknown tuberculin status. Methods:Transition-state model of clinical immune deterioration of HIV-infection over ten years, review of published data, and a survey of AIDS experts. Outcome measures are the numbers of tuberculosis cases and deaths prevented and isoniazid toxicity cases and deaths occurring with prophylaxis. Patients:Hypothetical cohorts of HIV-infected 40-year-olds. Results:Because the tuberculosis activation rate is so high in HIV-infected patients, the benefits of prophylaxis far outweigh the risks of isoniazid toxicity for tuberculin reactors with HIV infection at any stage of immune function: 1,469–2,868 tuberculosis cases and 170–274 deaths are prevented per 10,000 cohort over ten years, depending upon the cohort’s initial immune state. The benefits of prophylaxis outweigh the risks of isoniazid toxicity for anergic HIV-infected patients if they come from a community with a 2% to 3% or greater prevalence of Mycobacterium tuberculosisinfection. Conclusions:Isoniazid prophylaxis is a reasonable prevention measure for HIV-infected tuberculin reactors and for many HIV-infected anergic patients. Received from the Departments of Medicine, Community Medicine, and Biomathematical Sciences, the AIDS Center, and the Clinical Trials Unit, Mount Sinai School of Medicine, New York, New York. Presented in part at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991. Supported in part by the following grants: 1/RO1 MH45686 from the National Institute of Mental Health, and UO1 AI27667 and UO1 AI27554 from the National Institute of Allergy and Infectious Diseases.