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