TB and HIV co-infection in the EU/EEA: Focus on prisoners and people who inject drugs

TUBIDU Network meeting and study tour

Dr. Andreas SandgrenEuropean Centre for Disease Prevention and Control

Jõhvi/East Viru County, Estonia, 16-18 October, 2012

Vulnerable groups

Vulnerable groups include:• Homeless people• Prison inmates• Illicit drug users• Alcoholics• People living with HIV• Refugees, asylum seekers, migrants• Children and the elderly

Photo: Badische Zeitung, 2011

Prioritize vulnerable groupsECDC’s added value

More focus is needed on vulnerable groups in the EU

‘Identify and describe vulnerable populations for TB’:

- Surveillance

- Ad hoc surveys

-‘Decrease burden of TB/HIV’:

- Enhance TB/HIV surveillance

- Research and prevention actions

-‘Tailor interventions to vulnerable populations’:

- Approaches for detection and care

- Intensified case finding

The ECDC Framework Action Plan sets strategies to reach

TB elimination in the EU

It specifically addresses vulnerable populations

Enhancing TB-HIV co-infection surveillance at EU level – an ECDC project

Information collected to provide a better overall understandingof the TB-HIV co-infection situation in Europe.

• A comprehensive, systematic review of the current literature on TB-HIV co-infection burden (rates, numbers, and/or proportions)

• A survey of national surveillance contacts for HIV and TB, assessingthe extent of TB/HIV-co-infection data collection.

Service Contract

Health Protection Agency

United Kingdom

Survey on TB & HIV co-infection surveillance in the EU/EEA

Questionnaire:

• Sent 30 countries

• TB surveillance contact points

• HIV surveillance contact points

Focus of questionnaire:

• Data collection of TB/HIV co-infection

• Burden of co-infection

• Data confidentiality

• Legislation

• Testing practices

• Perceived limitations & barriers to data collection

28 responses

25 TB responses

7 HIV status not collected

18 include HIV status

2 match to HIV

database

16 clinician reporting TB

case

21 TB & HIV responses

11 data in both

systems

5 no record in any system

24 HIV responses

13 include TB status

1 match to TB database

9 HIV clinician reports

1 TB status frTB register

1 first AIDS + TB reg

1 sentinel clinsurveillance

study

11 TB status not collected

The proportion of diagnosed co-infections actually captured are not well known.

Estimates: 5-100% for the different Member States

Levels of reported TB/HIV co-infection:

HIV-infected TB patients TB in persons living with HIV/AIDS

Why low TB/HIV co-infection coverage?

Identified barriers

Anonymous HIV-testing and/or reporting

Patient confidentiality legislation

Lack of collaboration between TB and HIV surveillance systems

Resources – financial and human

Reluctance of clinician to report

Security of patient information

23 countries recommend testing TB patients for HIV

14 countries recommend screening

persons living with HIV/AIDS for TB

Suggested action

Stimulate collaboration

Promote HIV-testing and TB-screening

Increase national funding

Develop system of reporting HIV-status in TB-surveillance system

Develop matching between the two systems

Measure the real proportion of screening/testing individuals

CDC

HIV infections notified in 2009, all cases

Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2009

HIV prevalence among people who inject drugs; Europe, 2008–2009

10 < 50%

≥ 50%

Not included, not reporting, or not known

5 < 10%

Source: EMCDDA and ReitoxNational Focal Points (EMCDDA countries: EU, Croatia, Turkey and Norway); Mathers et al., Lancet 2008 (other countries). Colour indicates midpoint of national data, or if not available, local data. Data for EMCDDA countries are mostly from 2008–2009. If data are not available for 2008–2009, older data were used.EMCDDA data are sub-national for Turkey, UK, France, Slovakia, Netherlands, Belgium, Poland, Bulgaria, Spain, Sweden, Ireland, Latvia, Germany, Lithuania, Romania, Estonia. For non-EMCDDA countries, this information is not available.

0 < 5 %

HIV prevalence in IDUs in prisons and among

IDUs outside prison, EU, 2004 – 2010

Country Year of study

Sample size

% positive Prevalence in IDUsoutside prison (n)

Bulgaria 2005-06 724 0.0 - 2.7% 0.4 - 0.8% (1314),

Czech Republic 2010 168 2.4% 0.1 – 0.5% (3762)

Spain 2006 1194 39.7% 36.4% (9068), DT & PRI

Malta 2004 58 0.0% 1.3% (77)

Hungary 2009 85 0.0 0.0 (676)

Finland 2007 1363 0.1% 0.2% (1486), 2006

Sweden 2006-09 1249 0.0 - 7.7% 5.4 (203), 2007

Data courtesy of:

TB infections notified in 2010, all cases

13

≥ 50 cases per 100,000 population

< 10 cases per 100,000 population

Not included or not reporting

20-50 cases per 100,000 population

10-20 cases per 100,000 population

TB notification rates in the EU/EEA, in 2010

HIV prevalence among TB cases, 2010

17,650 TB cases with known HIV status in 2010.

Not included or not reporting

5.1 to 10.0 %

0.1 to 5.0 %

10.1 to 15.0 %

0.0 %

> 15.1 %

6.0% co-infection in 2010

* Data complete (known HIV status in > 50% TB cases)

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Risk groups among TB/HIV co-infected

Pimpin L et al, ERJ, 2011.

Prison case notification rates compared to country TB prevalence in EU

Country Country prevalence (per 100,000)

Prison case notification rate (per 100,000)

TB/HIV co-infection in IDUs and prisons in EU

(non-systematically collected data)

Country, Author, Publication year

Year of study

Sample size

TB/HIV co-infection

Population

Spain, Diez M, 2007 2000-2003 658 31% IDU’s with HIV

UK, Drobniewski, 2005 2001-2002 1344 12% Prisoners with TB

Spain, Marco, 2012 2008 173 14% Prisoners with HIV

Spain, Martin, 2000 1991-1997 796 20% IDUs, admission to prison

Seven key recommended interventions

• INJECTION EQUIPMENT

• VACCINATION

• DRUG DEPENDENCE TREATMENT

• TESTING

• INFECTIOUS DISEASE TREATMENT

• HEALTH PROMOTION

• TARGETED DELIVERY OF SERVICES

COMBINE THESE KEY INTERVENTIONS TO ENHANCE PREVENTION SYNERGY AND EFFECTIVENESS