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Tuberculosis among people who inject drugs: urgent actions needed.

This presentation discusses the urgent need for actions to address tuberculosis among people who inject drugs. It covers the magnitude of the problem, policy frameworks, key recommendations, operational issues, challenges, and conclusion. The presentation also provides information on the global burden of TB and the link between TB, injecting drug use, and incarceration. It highlights the importance of multisectoral coordination, TB screening and prevention, HIV testing and prevention, and integrated service delivery. The presentation also addresses the challenges faced in data collection, ownership, and collaboration among stakeholders.

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Tuberculosis among people who inject drugs: urgent actions needed.

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  1. IHRA’s 22nd International Conference, 3-7 April, Beirut, Lebanon. Tuberculosis among people who inject drugs: urgent actions needed.

  2. Outline of presentation • Magnitude of the problem and evidence • WHO, UNAIDS and UNODC policy framework • Key recommendations and operational issues • Challenges • Conclusion

  3. What is TB? • One in three are infected with M. tuberculosis • Risk of TB in PLHIV: 20-40X • Isoniazid prevents TB in PLHIV • Drug susceptible TB: curable with <20 USD/patient • Drug resistant TB • MDR: Resistance to INH & R • XDR: Resistance to 2nd line Transmitted by Coughing Sneezing

  4. The global burden of TB in 2009 Estimated number of deaths Estimated number of cases 9.4 million (range, 8.9–9.9 million) 1.3 million* (range, 1.2–1.5 million) All forms of TB (men and women) 0.5 million (range, 0.4–0.6 million) All forms of TB (in women) 3.6 million (38%) (range, 3.4–3.8 million) 0.4 million (range, 0.32–0.45 million) HIV-associated TB 1.1 million (12%) (range, 1.0–1.2 million) Multidrug-resistant TB (MDR-TB) ~0.15million 0.5 million *excluding deaths among HIV+ people

  5. No report Reported, no estimate >1000 500-1000 250-500 0-250 Prevalence of injecting drug use per 100,000 Incidence of TB per 100,000 population

  6. 0-4 5-9 10-19 20-39 40+ IDU report, no HIV HIV in PWID, no estimate No reports Prevalence of HIV among PWID (%) Estimated HIV prevalence in new TB cases (%) 0–4 5–19 20–49 50 and higher No estimate

  7. TB risk is high in PWUD regardless of HIV Pre-HIV era studies: 10x more risk of TB in PWUD • References • Askarian et alEast Mediterr Health J 2001; 7:461–4. • Howard et al Clin Infect Dis. (2002) 35 (10): 1183-1190 • Grimes et al Int J Tuberc Lung Dis 2007; 11:1183–9.

  8. TB disease risk is high among PWID

  9. TB, IDU and incarceration linkage • PLHIV who inject drugs and developed TB have a four fold increased risk of incarceration1 • Up to 74% prisoners injected and up to 94% shared equipment while in prison2 • 78% PWID were incarcerated and 30% injected while in prison3 References • J Epidemiol 2011 ;21 (2) :108-113 • Lancet Infec Dis 2009;9:57-66 • BMC Public Health 2009, 9:492 doi:10.1186/1471-2458-9-492

  10. TB in prison • 1 in 11 TB cases in high income countries • 1 in 16 TB cases in mid-low income countries Prison transmission PLoS Med 7(12): e1000381. doi:10.1371/journal.pmed.1000381 23 times more risk of TB disease in prisoners than the general population

  11. MDR TB is common among prisoners Ref : Dubrovina et al INT J TUBERC LUNG DIS 2008; 12:756–762

  12. Lower survival of TB patients who inject drugs

  13. HBV and HCV common among TB patients

  14. The policy guidance Recommendations • Multisectoral coordination • TB screening and prevention • HIV testing and prevention • Treatment of TB and co-morbidities • Integrated service delivery

  15. Functional multisectoral coordinating body • Composition • National AIDS and TB Programs • Harm reduction programs • Criminal justice system • Social care and psychological services • Representatives of people who use drugs • Functions • Favorable policy, programme and legislative environment • Promote evidence base practice and programs • Develop TB/HIV national strategic plan • Define roles and responsibilities of stakeholders

  16. TB screening and isoniazid preventive therapy (IPT) None of current cough, fever, night sweats or weight loss = No TB = IPT Getahun et al PLoS Medicine 2011 Symptom based TB screening is sufficient to exclude TB among PLHIV who use drugs and provide at least 6 months IPT

  17. IPT is not toxic to people who use drugs Excessive alcohol consumption (OR 4.2, P=0.002) and underlying liver disease (OR=4.3, P=0.002) are associated with hepatoxicity

  18. ART reduce TB risk by 54-92% among PLHIV Lawn et al Lancet Infect Dis 2010;10: 489–98 Co morbidities, including viral hepatitis infection (such as hepatitis B and C), should not contraindicate HIV or TB treatment for people who use drugs

  19. Integrated TB, HIV and HR services • Integrated service delivery initiated in 2008 : - TB/HIV/HR services - TB/HR services • In 2009-2010, 25 TB/HIV sites established • In one Kiev site in the first 6 months • 20 PLHIV on ST were diagnosed with TB • All of them CD4 <10 and were started ART • All of them completed TB treatment and CD4 >200 • Key factor for success: on site access for TB dx The example of All Ukrainian Network of PLHIV Konstantin Lezhentsev, TB/HIV CG meeting presentation, Almaty, May 2010.

  20. Key challenges • Absence of data and lack of ownership • Who should collect and communicate data? • Who should own the services? • Structural barriers • Lack of collaboration among stakeholders • Mandatory hospitalisation of TB patients in CAR and EE • Additive toxicities and perception of HCW • Stigma linked with multiple co-morbidities • Lack of awareness by activists and advocates

  21. TB/HIV Advocacy guide for HR advocates • HIT and INPUD with support by WHO, UNAIDS and IHRA • Based on existing TB/HIV experiences • Consultation on Sunday 3 April 2011 in Beirut. • Document will be available in July 2011. Stronger civil society voice to promote human rights based approach and accountability to the TB response

  22. Conclusion “Addressing TB among IDUs is a public health priority.” Consensus Statement of the Reference Group to the United Nations on HIV and Injecting Drug Use, 2010.

  23. Conclusion • Reliable global data on TB in people who use drugs and among prisoners urgently needed. • More TB ownership from prison and harm reduction services and vice versa needed. • Prompt co-treatment of TB, HIV and other co-morbidities among PWUD save lives. • Services should be scaled-up in a client friendly manner with due respect to basic human rights

  24. Acknowledgement • A. Ball • A. Baddeley • L. Blanc • R. Granich • C. Gunneberg • A. Reid • D. Sculier • C. Smyth • A. Verster

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