Justyna Kowalska, Prof, President of ECEE Network Group association
Dominik Bursa, MD, Secretary of the ECEE Network Group
Tuberculosis (TB) remains a leading cause of death in people with HIV (PWH), largely through re-activation of latent TB infection (LTBI). PWH have a 20–30-fold higher risk of LTBI re-activation, though it can be prevented by TB preventive treatment (TPT). While WHO recommends TPT for all PWH after excluding active TB, most evidence comes from high-incidence settings or the pre-antiretroviral therapy (ART) era, leaving gaps in guidance for low- and moderate-incidence settings. Challenges in implementing TPT persist, including limited data on uptake, completion, effectiveness, and treatment-related toxicities. Findings from the Stage 1 project revealed wide variations in national policies and practices for tackling LTBI in PWH, with scarce surveillance of LTBI screening and TPT. To address these gaps, this project will establish a regional research platform, harmonize strategies, and support evidence-based LTBI management in PWH across the CEE region.
The overall long-term aim is to strengthen the management of latent tuberculosis infection (LTBI) in people with HIV (PWH) across central and eastern Europe (CEE). The specific objectives are 1) improved knowledge of the effectiveness and impact of TPT (through operational research), 2) harmonized recommendations for LTBI management in PWH in the region (through policy recommendations), and 3) improved knowledge and awareness of LTBI among healthcare providers (HCP) and PWH (through educational initiatives). Through an international network of HIV clinicians, the project will generate real-life clinical data on LTBI prevalence, treatment uptake, and outcomes, while identifying barriers and opportunities for improvement. In parallel, it will promote harmonization of regional guidelines in line with WHO and other international standards and foster awareness and education among healthcare providers, policymakers, and affected communities. More specifically, the study will focus on reducing TB-related morbidity and mortality and advancing progress in Europe towards the global End TB Strategy.
The project will address barriers in LTBI management among PWH in the CEE region through three integrated activities. A prospective international cohort will be created, enrolling adults with HIV and documented or assumed LTBI from HIV clinics across 29 CEE countries. Data collection will include demographics, HIV clinical and laboratory information, co-infections, data on LTBI testing and screening for active TB, as well as information about TPT. Data collection will be performed at baseline and updated annually until minimum follow-up of 5 years for each patient unless death or lost-to-follow-up occur. Primary endpoints are TB disease and all-cause mortality; secondary endpoints include other AIDS-defining events. The expected sample size is over 1,000 PWH.
Existing guidelines and their implementation in clinical practice will be mapped against national policies to identify gaps, promote harmonization with WHO and European guidelines, and provide recommendations to the ECEE local focal points. Furthermore, educational workshops, webinars, and awareness initiatives will target HCPs from the CEE countries. Information about workshops will be disseminated through ECEE Network Group and by JUSTRI. A survey about knowledge of LTBI and barriers to testing, including associated stigma among PWH will be developed and conducted. The survey will be distributed by HIV centers.
This will be the first operational research study assessing real-life situations on management of LTBI in PWH in CEE. The direct outcome will be improved understanding of LTBI/HIV epidemiology and management in the region and identification of areas for improvement both on local and national levels. Ultimately, the project aims to contribute to reducing TB-related morbidity, mortality, and health inequities. A cascade of LTBI care will provide measurable baseline metrics for mapping against the End TB Strategy targets giving the possibility for monitoring and evaluation of the future progress. The best results will be set as a benchmark for LTBI-care. The results will influence further adjustment of targeted interventions and, thus, will have a direct impact on the improvement of LTBI care in Europe. The project will provide feedback to national and regional stakeholders and through this action strengthen the regional and countries’ capacities for TPT and systematic screening for active TB, active case finding, and present available implementation mechanisms and tools. Through education and awareness, the project will enhance knowledge, reduce stigma, and improve LTBI testing and treatment uptake.