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HIV and Tuberculosis interaction and integration. Anthony D Harries The “Union”, Paris, France London School of Hygiene & Tropical Medicine, UK. - PowerPoint PPT Presentation
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HIV and Tuberculosis interaction and integration
Anthony D Harries The “Union”, Paris, France London School of Hygiene & Tropical Medicine, UK
Epidemiology and Effects of HIV-TB Interaction
Risk of TB in persons withMycobacterium tuberculosis
Not HIV Infected
Life time risk = 5-15%
HIV Infected
Annual risk = 5-15%
Tuberculosis incidence rates (cases / 100 person-years) in HIV-infected patients prior to availability of antiretroviral therapy
in South Africa and Italy
Lawn et al, 2010: data adapted from Badri et al., 2002 and Antonucci et al., 1995
Growth in TB incidence in Eastern and Southern Africa, 1980-2004
0
100
200
300
400
500
600
700
1980 1985 1990 1995 2000 2005
Rep
orte
d TB
cas
es/1
00,0
00/y
ear Malawi
BotswanaKenyaS AfricaZimbabwe
3.2
3.4
3.6
3.8
4.0
4.2
4.4
0.0 1.0 2.0 3.0 4.0Ln (% HIV prevalence in adults, 15-49y)
Ln (%
TB
pat
ient
s th
at a
re w
omen
)HIV increases the number of young women with TB
Estimated HIV-prevalence in patients with TB
WHO Global Tuberculosis Control 2011
Advancing HIV immune suppression
[less inflammation and granuloma formation]
PTB
Smear-positive
Cavities
Upper lobe disease
PTB
Smear-negative
Infiltrations
Lower lobe disease
EPTB
Disseminated disease
Mortality rates in HIV-infected smear-positive PTB patients before era of ART
Country CD4 count in HIV-positive patients HIV-negative patients
<200 200-499 500 or >
Cote d’Ivoire: at 6 months 1
10% 4% 3% ~1%
Zaire: at 24 months 2
67% 22% 8% < 2%
1 Ackah et al, Lancet 1995; 345: 607-10; 2 Perriens et al, N Engl J Med 1995; 332: 779 – 84
Tugela Ferry, SA MDR-TB XDR-TB
Number 272 382
HIV-infected % 90% 98%
1-month mortality 40% 51%
1-year mortality 71% 83%
Gandhi et al, Am J Respir Crit Care Med 2010, 181: 80-6
Lethal combination of HIV and DR-TB
High rate of recurrent TB after successful treatment
HIV+ve HIV-veZaire 18% 6% (Perriens et al, 1991)
Kenya 17% 0.5% (Hawken et al, 1993)
Zambia22% 6% (Elliott et al, 1995)
S.Africa 16% 6% (Sonnenberg et al, 2001)
Number of people receiving antiretroviral therapy in low- and middle-income countries, by region, 2002–2010
Of HIV-infected patients who start antiretroviral therapy (ART) in Africa
• 8% - 26% die in first year
• Often due to diagnosed and undiagnosed TB
Lawn SD et al. AIDS 2008; 22: 1897 - 1908
TB Control derailed:
• More patients• More difficult
diagnosis• Higher mortality• Higher rate of
recurrence
HIV/AIDS care affected:
• Increased morbidity• Increased mortality
HIV effects on TB TB effects on HIV
How to decrease the joint burden of HIV and TB?
WHO Interim Policy: Jan 2004
• Milestone
• Clear guidance based on incomplete evidence
• Only 14 pages
• Multiple languages
• Adopted in > 160 countries and saved ~1 million lives in 8 years
Between 2004 and 2012, new evidence for
• TB prevention role of ART
• Expanded use of HIV testing for patients with suspected TB, family members or contacts
• Better integration of HIV-TB care
2012
C. Reduce HIV burden in patients with TB
Provider initiated HIV testing and counselling [PITC]
If HIV- seropositive
Start cotrimoxazole preventive therapy as soon as possible
Start antiretroviral therapy as soon as possible
B. Reduce TB burden in PLHIV
Active TB No active TB
Anti-TB Treatment
Isoniazid Preventive Therapy
Infection control (TB) in high risk settings
Intensified case finding for TB
Early antiretroviral therapy
A. Integrated services:
TB Clinic
ART Clinic
Number TB cases registered 340Number TB cases HIV tested 275 Number TB cases HIV-positive 192Number HIV+TB cases on CPT 186Number HIV+TB cases on ART 122
Number of patients on ART 1025No. screened for TB at last visit 825No. diagnosed with TB 8No. started on IPT 72Co-location or integration of clinics
TBHIV and HIVTB Monitoring
Are we making progress?HIV-TB Collaborative Activity Results for
2010
% HIV-infected persons in care actively screened for TB (ICF) 58
% HIV-infected persons in care and eligible and started on IPT 25
% TB patients tested for HIV 34
% HIV-positive TB patients started on CPT 79
% HIV-positive TB patients started on ART 46
WHO Report 2011 Global Tuberculosis Control
WE NEED TO DO BETTER:
• Funding: we have to meet the funding gap
• Knowledge: we need to continue doing the relevant science
• Implementation: we need to do what works and be accountable