Tuberculosis Preventive Treatment care pathways in people living with HIV: a systematic review and meta-analysis.

Abstract

BACKGROUND Tuberculosis Preventive Treatment (TPT) can reduce TB incidence and mortality in people living with HIV. However, low levels of screening and uptake, poor adherence, and loss to follow-up considerably reduce its effectiveness. We aimed, therefore, to assess the losses within all steps of the screening and treatment cascade. METHODS To enhance data generalizibility we included articles which reported the proportion of people living with HIV completing any step of the TPT cascade in low- and high-TB burden countries published before March 2024. Random effects meta-analysis produced pooled estimates of the proportion proceeding to the next step along the cascade. Results were explored through subgroup analyses and meta-regression. PROSPERO registration: CRD42020162396. FINDINGS Data from 368 cohorts containing 2.7 million participants were included. High levels of heterogeneity in outcomes were seen. Most participants were from Africa (80.6%). Isoniazid monotherapy was used for TPT in 92.6% of cohorts, usually for six months. Substantial loss to follow-up was found throughout the treatment cascade with more than one in six patients lost at the following steps: initial screening, immunological testing, treatment start and completion. Treatment regimens lasting four months or less were more likely to be completed than longer ones - 88.4% compared to 61.6%. INTERPRETATION Our analysis highlights substantial loss to follow-up at multiple steps during the care cascade. This may significantly lower the reported effectiveness of TPT in real-world settings. Research and policy should focus on simplified care pathways and novel, shorter treatment regimens that optimise retention in care.