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Annabel Baddeley Stop TB Department WHO, Geneva

Annabel Baddeley Stop TB Department WHO, Geneva. Tuberculosis and drug use: policy and evidence for action. Pierpaolo de Colombani European Region WHO, Copenhagen. Outline of presentation. Global and European burden and evidence WHO, UNAIDS and UNODC policy

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Annabel Baddeley Stop TB Department WHO, Geneva

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  1. Annabel Baddeley Stop TB Department WHO, Geneva Tuberculosis and drug use: policy and evidence for action Pierpaolo de Colombani European Region WHO, Copenhagen

  2. Outline of presentation • Global and European burden and evidence • WHO, UNAIDS and UNODC policy • Examples of integrated service delivery • Challenges • Conclusion

  3. The global burden in 2011 Estimated number of cases Estimated number of deaths All forms of TB 0.99 million1 (range, 0.84–1.1 million) 8.7 million (range, 8.3–9.0 million) HIV-associated TB 0.43 million (range, 0.4–0.46 million) 1.1 million (12%) (range, 1.0–1.2 million) IDU-related HIV 3 million (19%)2 (range, 0.76-6.6 million) More data needed IDU-associated TB More data needed More data needed • Excluding deaths among HIV+ve people • Estimated prevalence in 2007,Mathers et al, The Lancet 2008, 372:1733-1745

  4. Estimated TB burden; world, 2011 www.worldmapper.org 8.7 (8.3-9.0) million in the world 380 000 (350-400) in WHO Europe Global tuberculosis control: WHO report 2012. Geneva: WHO, 2012

  5. No report Reported, no estimate >1000 500-1000 250-500 0-250 Mathers et al, The Lancet 2008, 372:1733-1745 Prevalence of HIV among PWID (%) Prevalence of injecting drug use per 100,000 Beyrer et al, The Lancet 2010; 376:551-563 Numbers show regional PWID estimates

  6. HIV in PWIDs per 100,000, 2010 Estimated HIV in TB cases (%), 2010 HIV/AIDS surveillance in Europe 2010. ECDC/WHO, Stockholm TB surveillance and monitoring in Europe 2012. ECDC/WHO, Stockholm

  7. Drug use, TB, HIV and incarceration • PWIDS & ex-PWIDS found to be 5 times more at risk of TB/HIV after 23 months in prison than at time of admission1 • Up to 74% prisoners injected and up to 94% shared equipment while in prison2 • 78% PWIDs reported history of incarceration and 30% injected while in prison3 1. Martin et al, INT J TUBERC LUNG DIS 4 (1):41-46 (Spain) 2. Jürgens et al, Lancet Infec Dis 2009;9:57-66 (Australia) 3. Hayashi et al, BMC Public Health 2009, 9:492 doi:10.1186/1471-2458-9-492 (Thailand)

  8. Exposure to higher rates of MDR Dubrovina et al Int J Tuberculosis Lung Dis 2008; 12:756-762 (Ukraine) TB surveillance and monitoring in Europe 2012. ECDC/WHO, Stockholm

  9. PWIDs with HIV at higher risk of TB HIV/AIDS surveillance in Europe 2010. ECDC/WHO, Stockholm

  10. Inequitable access to ART Wolfe et al, The Lancet 2010; 376:355-66.

  11. So what does WHO recommend? http://www.who.int/tb/publications/2012/tb_hiv_policy_9789241503006/en/index.html http://www.who.int/hiv/pub/idu/tb_hiv/en/index.html http://www.who.int/hiv/pub/idu/targetsetting/en/index.html http://www.euro.who.int/__data/assets/pdf_file/0014/152015/e95786.pdf

  12. Integration and colocation of services

  13. Policy guidelines for TB and HIV services for drug users Joint Planning Service providers National & local coordination body Plans with roles, responsibilities & M&E Human resources and training available Support to operational research Package of Care TB infection control plans in care settings Case finding protocols at services drug users present Treatment services for TB and HIV available Isoniazid prevention available HIV prevention (Harm Reduction Package) Overcoming Barriers Integrated services (Link TB/HIV treatment and harm reduction Equivalence of care in prisons Adherence support measures Comorbidity not to be used to withhold treatment

  14. TB is a key component of harm reduction • Needle and syringe programmes (NSP) • Drug treatment including Opioid Substitution Therapy (OST) • Voluntary HIV Counselling and Testing (VCT) • Anti-Retroviral Therapy (ART) • Sexually Transmitted Infections (STI) prevention and treatment • Condom programming for IDUs and partners • Targeted Information, Education and Communication (IEC) • Hepatitis diagnosis, treatment) and vaccination of A&B • Tuberculosis (TB) prevention, diagnosis and treatment

  15. Strengthened TB, HIV and harm reduction • Improve TB/HIV collaboration: revise national policies & establish functional TB/HIV coordinating mechanisms • Provide drug dependence treatment, intensive TB case-finding, isoniazid preventive therapy & TB infection control in HIV facilities. • Engage civil society

  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. ART reduces 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

  18. IPT is not toxic to people who use drugs Fernandez-Villar et al Clinical Infectious Diseases 2003; 36:293–8 Excessive alcohol consumption (OR 4.2, P=0.002) and underlying liver disease (OR=4.3, P=0.002) are associated with hepatoxicity

  19. New diagnostics

  20. Documented examples of integration http://www.euro.who.int/__data/assets/pdf_file/0005/165119/e96531.pdf http://www.aidsmap.com/Collaborative-TB-and-HIV-services-for-drug-users/page/1411949/ http://www.euro.who.int/en/where-we-work/member-states/ukraine/publications3/building-integrated-care-services-for-injection-drug-users-in-ukraine

  21. Integration of TB & HIV services at harm reduction settings Theo Smart, aidsmap, HATIP, Issue 159, 28th May 2010

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

  23. TB/PWID indicators • Number of drug support centres collaborating with National TB programme • Number of new TB cases registered in the year who were injecting drug users. • Number of TB cases detected at drug support centres. • Revised 2012 WHO, UNODC and UNAIDS Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for people who inject drugs shortly to be published. Stakeholders are urged to report TB/PWID data nationally

  24. 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

  25. Further reading: Treatment of Tuberculosis Guidelines WHO 2009 http://who.int/tb/publicationsMore information on TB drug interactions is available in Chapter 8.3 and the websites of the Global Drug Facility and the WHO Essential Medicines Library: http://www.stoptb.org/gdf/drugsupply/drugs_available.asp and http://www.who.int/emlib/Medicines.aspx Antiretroviral Therapy for HIV Infection in Adults and Adolescents 2010 revision http://www.who.int/hiv/pub/arv/adult2010/en/index.html Guidance on prevention of viral hepatitis B and C among people who inject drugs http://www.who.int/hiv/pub/guidelines/hepatitis/en/index.html TB Advocacy Guide for people who use drugs http://www.stoptb.org/wg/tb_hiv/assets/documents/TBHIV_Advocacy_Guide.pdf TB/HIV Working Group: http://www.stoptb.org/wg/tb_hiv/default.asp WHO HIV & PWIDs: http://www.who.int/hiv/topics/idu/en/index.html

  26. Acknowledgement • H. Getahun • R. Granich • C. Gunneberg • L. Nguyen • T. Smart • A. Verster

  27. Spare slides

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