1 / 33

HIV and TB in my Region: Is Anyone Listening?

HIV and TB in my Region: Is Anyone Listening?. Soumya Swaminathan, MD Director, National Institute for Research in Tuberculosis, Chennai India. WHO Report 2013 Global Tuberculosis Control. Worldwide, 8.6 million new incident cases of TB in 2012; 1.3 million TB deaths. ~1.13 million (13%)

nau
Download Presentation

HIV and TB in my Region: Is Anyone Listening?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. HIV and TB in my Region: Is Anyone Listening? Soumya Swaminathan, MD Director, National Institute for Research in Tuberculosis, Chennai India

  2. WHO Report 2013Global Tuberculosis Control Worldwide, 8.6 million new incident cases of TB in 2012; 1.3 million TB deaths ~1.13 million (13%) HIV+TB cases; 320,000 HIV+TB deaths in 2012

  3. Top Causes of YLL in 1990 and 2013: Global Burden of Disease Study

  4. HIV-Associated TB: Challenges and Key issues • One-third of the 35 million people living with HIV worldwide are infected with latent TB. • Persons co-infected with TB and HIV are 30 times more likely to develop active TB disease • TB is the most common presenting illness among people living with HIV, including those who are taking antiretroviral treatment. • TB is the leading cause of death among people living with HIV, accounting for one in five HIV-related deaths. • People living with HIV are facing emerging threats of multi-drug resistant (MDR-TB) and extensively drug resistant TB (XDR-TB)

  5. Percentage of TB patients with known HIV status, 2004 - 2012

  6. HIV testing, treatment for HIV+TB patients and prevention of TB among people living with HIV, 2012

  7. Collaborative TB/HIV activities 2004-2012SEARO

  8. Collaborative TB/HIV activities 2004-2012WPRO

  9. Trends in Number (%) of registered TB patients with known HIV status, 4q08- 1q14, India

  10. Proportion of TB patients with known HIV Status Nation-wide, 63% of TB patients with known HIV status • 56% of 13072 of microscopy centres have co-located HIV testing facilities • Northern States • Low HIV Prevalence • Limited HIV Testing and Care Facilities

  11. Clinical Challenges in HIV/TB • How to suspect and diagnose TB earlier among HIV+ persons? • Treatment – drug interactions, IRIS • MDRTB – new drugs, better regimens • TB in HIV+ children • How to prevent TB among HIV+ persons? • Service integration

  12. Diagnostic Issues • More extra-pulmonary, disseminated TB • Active case-finding required • Smear negative TB more common: sputum culture or more sensitive diagnostics for M.tuberculosisneeded • 504 patients with cough and negative sputum smears • Cough > 2 weeks had sensitivity of 97%, specificity of 6% • CXR had a sensitivity and specificity of 72% and 57% • Normal x-ray does not rule out TB – sputum culture positive in 7% of patients with normal CXR vs 21% with abnormal CXR • “Smear neg. TB” could be other OI’s – need facilities for additional investigations Swaminathan et al IJTLD 2004, AIDS 2003;17:1398-400, Padmapriyadarsiniet al JAIDS 2013,

  13. Top 5 Best Performing Rules in all Subjects with suspected TB (n = 8173), Getahun et al Plos Med 2011 CC: Cough in the last 24 hours; F: Fever; H: Haemoptysis; NS: Night sweats; WL: Weight loss

  14. Cepheid GeneXpert MTB/RIF • Molecular beacons target rpoB gene that covers mutations in > 99.5% of RIF-resistant isolates • Sensitivity in HIV+ 78% • Specificity 98% • Good for extrapulmspecimens (except PF) • Now recommended by WHO as preferred diagnostic test in smear negative TB, HIV+ persons and children Lawn, et al. PLoS Med 2011; Theron, et al. Am J RespCrit Care Med 2011; Scott, et al. PLoS Med 2011; Boehme et al. Lancet 2011; Cochrane Review 2014, WHO guidance 2014

  15. Sensitivity and specificity of Xpert MTB/RIF for detection of PTB in HIV-positive individuals with symptoms (16 studies)

  16. CB-NAAT for TB Diagnosis in Programmatic Settings: Feasibility Study in India • Objectives: Establish the feasibility and impact of decentralized deployment of routine CBNAAT testing of all pulmonary TB & DR-TB suspects in selected geographic areas • Approach: Programmatic demonstration: Before & after comparison from same sites; Phased implementation • ~9 million population, 18 sites Courtesy: FIND India

  17. Performance among HIV+ and Pediatric Patients

  18. Urine Lipoarabinomannin ELISA • Meta-analysis of LAM studies(Flores LL, et al. Clin Vaccine Immunol 2011; 18:1616-27) • Pooled sensitivity 47% in HIV(+) vs. 14% in HIV(-); specificity 96%-97% • Highest sensitivity in those with CD4 < 50 (67%-85%) (Lawn S, et al. AIDS 2009; Shah M, et al. JAIDS 2009)

  19. Sensitivity of Urine MTB/RIF in Sputum Scarce HIV-Infected Patients Peter JG, et al. PLoS One 2012; 7:e39966

  20. TB in HIV-infected children • 2678 HIV-infected children over 13 year period in TREAT Asia pediatric HIV cohort – 457 developed pulmonary TB (period prevalence 17%), 1/3rd of those tested bacteriologically confirmed • 21 deaths, 4.3% • Median CD4 9%, 185 cells/mm3 • 82% favourable outcomes • In ART Clinics in India, incidence of TB among HIV+ children (80% on ART) was 2.4/100py (poster • TB common in Asian HIV-infected children, especially if immunosuppressed • Diagnosis is challenging, training needed in specimen collection and CXR reading • IRIS – mostly paradoxical type. Little information on incidence, risk factors, management and prevention Sudjaritruk et al. AIDS Patient Care and STDs 2013 Dec, Bhavani PK etal, IAS 2014

  21. Pulmonary TB in HIV-infected or severely malnourished children with pneumonia • Reviewed studies that confirmed the etiology of acute pneumonia in < 5 years children with SAM (WAZ z score <-3) or HIV infection • Specimens collected by gastric lavage, BAL, percutaneous lung aspirate or induced sputum • 6 studies, 747 children included – 93 (12%) had active TB • Of 610 HIV+ children (s Africa), 10% had TB • Pulmonary TB more common than suspected in acute pneumonia with SAM or HIV infection • In children < 2 years, severe extrapulmonary manifestations eg TB meningitis common Chisti et al. J Health PopulNutr 2013 Sep

  22. Measured % of TB cases with MDRTB, WPRO

  23. Measured %of TB cases with MDRTB, SEA

  24. Baseline Isoniazid Resistance and HIV are Strong Risk Factors for Acquired Rifampicin Resistance: Analysis of 3 Cohorts Treated with 3/weekly anti-TB treatment (Narendranetal CID in press)

  25. For MDRTB, Prevention is Best Policy… MDRTB prevalence similar to HIV- populations Drug resistance testing (molecular methods) at initiation of treatment Treat HIVTB patients with appropriate anti-TB regimen Early HAART Ensure adherence and determine outcome New TB drugs – Delamanid and Bedaquiline approved Treatment: > 20 months with 2nd line drugs (6K,Emb,Eth,Z,Levo,Cyclo/14-18Emb,Eth,Levo, Cyclo) Favourable outcome in MDRTB 50-60%, XDRTB ~25%

  26. No ART ART <200 200-350 >350 CD4 Count Prevention of TB: Immune Status is Key TB Incidence by HAART Status and CD4 Counts • Prevalent TB at the time of HIV diagnosis was 10% in THRio study sites, Brazil • After adjustment for sex, age, baseline CD4 and baseline viral load, risk of death was significantly higher among prevalent TB cases, aHR=1.72(CI 95% 1.2-2.5) • Best method of TB prevention is to prevent immune deficiency  earlier HIV diagnosis and treatment Saraceni et al JAIDS 2014 Jun M.Badri, D.Wilson, R.Wood. Lancet 2002

  27. Preventive Therapy – More than Treatment of Latent TB Infection • BOTUSA trial: 36H more efficacious than 6H, especially among TST+ and those receiving ART • S Africa: 6H, lifelong H, 3RH2 and 3RifHowhad similar efficacy • India: 6EH and 36H similar efficacy • Rangaka: 12H reduced incidence of TB in patients on HAART, both TST+ and TST- • Among s African miners, incidence of TB in population not reduced by IPT, though individual protection + • In Brazil, implementation of package (intensified case finding, TST and IPT) reduced TB incidence in ART clinics • Limited experience in Asia-Pacific Samandari, Lancet 2011, Martinson et al NEJM 2011, Swaminathan Plos One 2012, Rangaka Lancet 2014, Churchyard NEJM 2013, Durovni Lancet 2013

  28. Elimination of TB will require attention to Latent TB Infection also CHILDREN HIV-INFECTED PERSONS HIV+ persons without active TB Simple 4 symptom screen high NPV INH daily for 6 or 36 months - shorter regimens in trial Regardless of TST result and ART status Vietnam, Cambodia, India scaling up IPT • Children < 6 years in contact with infectious TB • Regardless of TST result • Regimen: INH 10 mg/kg daily for 6 mo • Shorter regimens needed to improve compliance • Currently, only 15-20% of child contacts being screened and initiated on IPT

  29. Integrating Services – TB, ART, MCH, OST…. • ART integration into MNCH facilities and TB treatment settings led to coverage and  mortality • Integration and decentralization did not lead to adverse outcomes • Partial decentralization led to reduced attrition in care • Newer models – community/home provision of ARV, couriering of drugs need assessment Suthar AIDS 2014 Mar, KredoCochrane Database Syst Rev 2013 Jun

  30. Research Needs • Strategies for Reduction of mortality in TB/HIV • Strategies for prevention of TB in HIV+ adults and children, including research on biomarkers to predict disease progression from LTBI • Pharmacokinetics of 2nd line and new anti-TB drugs in children and adults with HIV • Optimize treatment for HIVTB children < 3 years, including Rifabutindosage • Shorter, safer and more convenient TB treatment regimens for DS and DRTB • Service integration, more patient-friendly services for HIVTB: different models of care

  31. Acknowledgements • My colleagues at NIRT, Chennai • DrHavlir, Getahun and others for informative discussions over the years • Dr BB Rewari, Dept AIDS Control • Dr KS Sachdeva, Central TB Division • Patients and their families

More Related