The number one killer of HIV patients in resource-limited areas, including parts of Africa and India, is tuberculosis (TB), underscoring the need for optimal treatments and effective strategies to address this deadly co-infection. But TB is harder to detect in HIV-infected patients and diagnostic test results take time, so many healthcare providers prescribe multi-drug TB treatments as a precaution. However, for the first time, findings from a large, randomized clinical trial show that this aggressive approach does not save more lives, researchers from Penn Medicine and other institutions report in The  Lancet.

The preventive therapy isoniazid—recommended by the World Health Organization (WHO) for HIV patients in these areas—was well tolerated and resulted in similar survival rates compared to a four-drug TB treatment, the researchers found in a study of almost 850 patients from 18 different sites in 10 countries.

“We don’t necessarily need to subject all these patients to multi-drug regimens,” said Gregory P. Bisson, MD, MSCE, an assistant professor in the division of Infectious Diseases and a senior scholar at the Center for Clinical Epidemiology and Biostatistics at Penn’s Perelman School of Medicine, and co-lead author of the study. “This new study shows that simple TB screening and isoniazid is a sufficient course of HIV care for this group, despite their very advanced HIV disease stage. Our participants were able to tolerate isoniazid very well, and we saw no evidence that they developed drug resistance more commonly, as is often feared.”

The trial, known as REMEMBER (Reducing Early Mortality and Early Morbidity by Empiric Tuberculosis), involved centers and institutions working in various countries around the globe, including the Perelman School of Medicine, Johns Hopkins University, and the University of North Carolina School of Medicine, among others. The 18 study sites were located in Malawi, South Africa, Kenya, Zambia, Zimbabwe, Uganda, Peru, Haiti, Brazil and India, all areas disproportionately affected by HIV and TB.

The WHO reports that in 2013 a quarter of all deaths among people living with HIV was due to TB.  However, TB screening rates remain low in resource-limited areas, according to the WHO, whose current guidelines recommend that healthcare providers screen HIV positive individuals for TB and use isoniazid to prevent TB in those who are not diagnosed with TB.

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