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Gavin J. Churchyard

TB and HIV management in high prevalence settings: From co-ordination to integration The Scientific perspective. Gavin J. Churchyard. Overview. WHO TB/HIV collaborative activities Decreasing the burden of TB in PLHIV Decreasing burden of HIV in TB patients Conclusions. NO. more people

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Gavin J. Churchyard

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  1. TB and HIV management in high prevalence settings: From co-ordination to integrationThe Scientific perspective Gavin J. Churchyard

  2. Overview • WHO TB/HIV collaborative activities • Decreasing the burden of TB in PLHIV • Decreasing burden of HIV in TB patients • Conclusions NO more people living with HIV dying of TB

  3. WHO policy on collaborative TB/HIV activities • Collaboration • planning, coordination, surveillance, M&E • Decrease the burden of TB in PLWHIV • Intensified tuberculosis case finding • Isoniazid preventive therapy • Infection control • Decrease the burden of HIV in TB patients • HIV counselling and testing • HIV prevention, care and support • Antiretroviral therapy 3Is

  4. # PLHIV screened for TB 2003-2008 1384458 (4%) 728929 364261 (Source: H Getahun. SA TB Conference. 2010)

  5. # PLHIV started on IPT 2003- 2008 48120 (0.2%) 25553 7359 (Source: H Getahun. SA TB Conference. 2010)

  6. Intensified TB case finding

  7. Prevalence of undiagnosed active TB in PLHIV (Khan et al. CID. 2010, Churchyard et al. AIDS. 2010. under review)

  8. A prospective observational study before and after implementation of the WHO algorithm for diagnosis of smear negative TB Survival after eight weeks 84% (157/187) of WHO algorithm patients 68% (241/351) of standard patients (OR 2.5, 95% CI 1.6-3.8). Impact on mortality of WHO guideline for diagnosis of smear negative TB (Rustomjee et al. SA TB Conference. 2010)

  9. DETECTB • Cluster randomised trial of 2 periodic intensified case finding strategies in Harare • Door to door • Mobile van • Substantial decline in undiagnosed TB • HIV-uninfected 59% reduction • HIV-infected 22% reduction (Corbett et al, Union Conference. 2009)

  10. Point of care diagnostics: new • Cepheid GeneXpert • FIND demonstration studies: preliminary results • >5 sites, > 1500 TB suspects • Sensitivity • S+ 99.5% • S- 90.2% • Rif resistant 97.5% • Specificity • Non-TB 98.1% • Rif sensitive 98.1% (Source: G Roscigno, IAS, CT, 2009)

  11. Isoniazid preventive therapy

  12. Standardised screening for TB in PLHIV: meta-analysis Best rule: one of current cough, fever, night sweats and weight loss (Getahun et al. AIDS2010. MOPE0128)

  13. Effect of IPT and ART on TB incidence and mortality

  14. Reduction in TB incidence with 36 vs 6 months IPT (Martinson et al. Union conference, 2008, CROI 2009) (Samandari et al. Union Conference. 2009)

  15. Administrative Controls Environmental Controls Personal Protection Infection Control Hierarchy of Controls for the Prevention of TB Transmission

  16. Natural ventilation for transmission of TB Increasing natural ventilation by opening doors and windows is associated with >2x greater number of air changes / hour than mechanical ventilation 28 vs 12 ACH (Escombe et al; PLoS Medicine 2007)

  17. (Escombe et al; PLoS Medicine: 2009, 2008) Guinea pigs exposed to HIV-infected PTB patients 70% of TB infection in GPs prevented by UV lights 90% of TB transmissions occurred from inadequately treated MDR TB patients UV lights and effective treatment reduce TB transmission

  18. Integrated TB and HIV treatment

  19. Timing of ART initiation during TB treatment: SAPIT (HR0.44, 0.25 to 0.79; P=0.003) (Karim et al. NEJM. 2010)

  20. Timing of ART initiation during TB treatment: CAMELIA • Starting ART 2 or 8 weeks after initiating TB treatment in severely immunosuppressed HIV-infected Cambodian adults • THLBBB1 – late breaker Track B -1

  21. Conclusions • Integration of TB and HIV activities is poor but improving • Intensified case finding, isoniazid preventive therapy and infection control must be scaled up • All individuals presenting to health care facilities should be screened for TB • The integration of ART with IPT and TB treatment should also be scaled up

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