Integration of TB and HIV: marked reductions in TB incidence after introduction of ART
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Integration of TB and HIV: marked reductions in TB incidence after introduction of ART Ole Kirk, MD, DMSc Kuala Lumpur 2 nd July 2013
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Integration of TB and HIV: marked reductions in TB incidence after introduction of ART. Ole Kirk, MD, DMSc Kuala Lumpur 2 nd July 2013. Proportions of adult TB cases attributable to HIV in 2000. Corbett , Arch Intern Med 2003. - PowerPoint PPT Presentation
Transcript of Integration of TB and HIV: marked reductions in TB incidence after introduction of ART
Integration of TB and HIV: marked reductions in TB incidence
after introduction of ART
Ole Kirk, MD, DMScKuala Lumpur 2nd July 2013
Proportions of adult TB cases attributable to HIV in 2000
Corbett, Arch Intern Med 2003
Increasing TB incidence due to HIV in the early 1990’s in Spain
Vall Mayans, AIDS 1997Castilla, AIDS 1997
TB of all AIDS cases: Spain (all) 1996: 39%Catalonia 1994: 37%
Marked CD4 gradient in TB incidences in the pre-cART era
<200 cells/mm3: 21.9 (17.9-26.6)200-349: 6.4 (4.5-8.9) 350-500: 3.2 (1.9-5.0)>500: 3.3 (2.3-4.8)
Lodi, Thorax 2013
<200 200-349 350-500 >5000
5
10
15
20
25
30incide
nce
(events /1000 PYFU)
Current CD4:
Decline in TB incidences when cART was introduced
<09-
95
09-9
5 - 0
3-96
03-9
6 - 0
9-96
09-9
6 - 0
3-97
03-9
7 - 0
9-97
09-9
7 - 0
3-98
03-9
8 - 0
9-98
09-9
8 - 0
3-99
03-9
9 - 0
9-99
09-9
9 - 0
3-00
>03-
00
0
0.5
1
1.5
0102030405060708090
tuberculosis, pulm.
tuberculosis, extrapulm
cART
Incidence (events/10
00 PYF)
% o
n cA
RT
Kirk, AJRCCM 2000; modified
15
10
5
<09-95 09-95 - 03-97 >03-970
1
2
3
4
5
<50 cells/mm3 50-100 100-200 >200
Inci
denc
e (e
vent
/100
0 PY
F)
Kirk, AJRCCM 2000
Decline in TB incidence due to cART and CD4 increases
50
40
30
20
10
Current CD4:
Effect of cART duration on TB incidence
Girardi, CID 2005
0-3 4-6 7-12 13-24 25-3602468
1012141618
Incide
nce
(event/1000 PYFU
)
Months since cART initiation
TB incidences following cART initiation - influence of CD4 level
Lodi, Thorax 2013
CD4 <50/mm3 CD4 50-199/mm3
CD4 200-349/mm3 CD4 >350/mm3
Lodi, Thorax 2013
CD4 <50/mm3 CD4 50-199/mm3
CD4 200-349/mm3 CD4 >350/mm3
CD4 <50/mm3
TB incidences following cART initiation - pronounced effect at low CD4
Kruk, AIDS 2011
TB incidence remains high in Eastern Europe
Mortality differences in Europe after a TB diagnosis
33%
8-14%
Podlekareva, AIDS 2009
HIV+ people with TB in Eastern Europe die from TB
Podlekareva, ERJ 2013 (in press)
EE WEA EE WEA EE WEA0
20
40
60
80
100
< 3 months > 12 months3-12 months
TB
Non-TB AIDS
Non-AIDS infections
HBV/HCV
Toxicity to anti-TB drugs Other
Unknown
N deaths 80 18 79 16 114 13with CoDeforms available
TB-recurrence
Time after TB diagnosis
Prop
ortio
n of
dea
ths
due
to v
ario
us c
ause
s
Conclusions
• Marked decreases in TB incidences in Western Europe after an intense scale-up of cART
• Pronounced effect of cART when started at low CD4 count, whereas the effect was minimal at higher CD4 levels
• Usage of cART was associated with a lower risk of TB-related death in HIV+ people already diagnosed with TB
Implications
• Urgent need to identify and treat HIV+ people at high risk of TB
• Treatment of HIV+ people with low CD4 levels seems to be an efficient way to reduce the risk of TB
