THE 6 TH NATIONAL SCIENTIFIC CONFERENCE ON HIV/AIDS Yield and impact of repeated screening for...
-
Upload
andrea-stewart -
Category
Documents
-
view
224 -
download
0
description
Transcript of THE 6 TH NATIONAL SCIENTIFIC CONFERENCE ON HIV/AIDS Yield and impact of repeated screening for...
THE 6TH NATIONAL SCIENTIFIC CONFERENCE ON HIV/AIDS
Yield and impact of repeated screening for tuberculosis
and isoniazid preventive therapy among patients with HIV in Vietnam
Duong BD1, Thai LH2, Cowger T2, Nhung NV3, Nhan DT1, Thoa CK1, Khanh VT4, Thinh T5, Dung NH6, Yen NTB6, Ngoc DV5, McConnell M2, Whitehead S2, Pevzner ES2.
Presenter: Duong BD
1 Vietnam Authority for HIV/AIDS Control;2 U.S. Centers for Disease Control and Prevention;3 National Lung Hospital; 4 VAAC-U.S. CDC Cooperative-agreement Project; 5 Ho Chi Minh City
Provincial AIDS Committee; 6 Pham Ngoc Thach Hospital.
The 6th National Scientific Conference on HIV/AIDS
Background Tuberculosis leading infection and cause of death in
people living with HIV (PLHIV) Diagnosis challenging
Previously, no evidence-based algorithm to screen/diagnose TB in PLHIV
2007: CDC with Vietnam, Cambodia, Thai HIV and TB programs conducted ID-TB/HIV study to identify algorithm to screen for, diagnose and rule out TB
Identified algorithm screens for 3 symptoms: 1) cough of any duration; 2) fever of any duration; 3) night sweats >3 weeks
2010- 2011: CDC and Vietnam HIV-TB programs conducted study to evaluate algorithm in programmatic conditions
The 6th National Scientific Conference on HIV/AIDS
Study objectives To evaluatethe diagnostic yield of screening for TB and using the diagnostic algorithm at baselinethe diagnostic yield of TB screening and diagnosis algorithm during follow-up
the outcomes of PLHIV screening negative and starting IPTthe impact of ART and IPT on risk for TB among PLHIV during follow-up
the impact of routine screening for TB using the algorithm on mortality among PLHIV
The 6th National Scientific Conference on HIV/AIDS
Methods: Study sites and subjects
One-year longitudinal cohort study
Study sites: 3 HIV outpatient clinics (OPC) in Hanoi and
HCMC
Subjects Eligible: HIV+ patients aged >15 years and not yet receiving ART
At each clinical encounter screened using TB algorithm
Ineligible for follow-up if diagnosed with TB or currently
receiving anti-TB treatment
The 6th National Scientific Conference on HIV/AIDS
Methods: Data collection At enrollment:
‒ Eligibility and demographic data
‒ Physical exam findings
‒ Medical history
‒ TB-related medications
‒ Date and screening results At each clinical encounter:
‒ Date and screening results
‒ Deviations from the diagnostic algorithm
‒ Dates of ART and/or IPT initiation
‒ CD4 values
‒ Dates of death, LTFU, TB diagnosis
The 6th National Scientific Conference on HIV/AIDS
Data analysis
• Bivariable and multivariable analysis of relationships between predictors and screening results during follow-up
• Time-to-event analyses of incident TB and death
The 6th National Scientific Conference on HIV/AIDS
Yield of Repeated TB Screenings
The 6th National Scientific Conference on HIV/AIDS
Yield of Repeated TB Screenings
The 6th National Scientific Conference on HIV/AIDS
Incidence of TB at enrollment and follow-up screenings
*An additional 16 cases of TB diagnosed at non-study sites during follow-up
1-year period prevalence was 12,421 per 100,000 persons*
The 6th National Scientific Conference on HIV/AIDS
Time to incident TB
Time to TB: •Median: 88 days•IQR: 64-142 days
29 Cases of incident TB•Incidence: 4,966 per 100,000
The 6th National Scientific Conference on HIV/AIDS
ART and IPT initiation during follow-upAt 1 year, 85% of participants were on ART and/or IPT & 33% were on both ART and IPT
The 6th National Scientific Conference on HIV/AIDS
IPT and TB Risk
aHR: 7.7 (2.0, 33.3)
Not on IPT
On IPT
aHR: adjusted hazard ratio. HR adjusted for gender, age, baseline BMI, CD4 count at enrollment, ART, previous TB, smoking
The 6th National Scientific Conference on HIV/AIDS
ART and TB risk
ART <3 months v. ART >3 monthsaHR: 16.9 (4.2, 68.2)
ART <3 months
No ART
No ART v. ART >3 monthsaHR: 12.1 (2.5, 59.0)
ART >3 months
The 6th National Scientific Conference on HIV/AIDS
Impact of regular TB screening on mortality
Regular follow-up screenings <120 days:•aHR: 1.56 (0.34, 7.1) Regular follow-up
screenings >120 days:•aHR: 10.0 (2.5, 100)
aHR: adjusted hazard ratio. Hazard ratio adjusted for gender, age, baseline BMI, CD4 count at enrollment, ART, Injection drug use, and smoking
The 6th National Scientific Conference on HIV/AIDS
Main findingsDiagnosing TBHigh incidence of TB observed at enrollment and follow-upDeclining proportion of persons screening TB positiveDeclining proportion of persons diagnosed with TB
Preventing TBHigh uptake of ART and IPT among participantsLower TB incidence among participants prescribed IPT Higher TB incidence among participants not on ART or <3 months ART
Program impactLower mortality among PLHIV screened regularly for TB
The 6th National Scientific Conference on HIV/AIDS
Limitations• Observational data - participants not randomized to receive
repeated screenings
• No external comparison group
• Small number of events (TB & death) limited ability to statistically assess more complicated models. Couldn’t assess the joint effect of ART & IPT
• Purposeful selection of study sites so conclusions may not be generalizable to other sites in Viet Nam
• Gold standard diagnostic results not available for all participants so could not calculate sensitivity and specificity
The 6th National Scientific Conference on HIV/AIDS
Conclusions
Benefits of Repeated Screening Opportunities for initiation of ART and IPT
Additional opportunities to diagnose TB for PLHIV with missed or incomplete diagnostic evaluations
Treatment or referral for other health services
The 6th National Scientific Conference on HIV/AIDS
Recommendations
• Routine screening for TB in every visit, using TB screening and diagnosis algorithm in line with national guidelines
• Facilitating PLHIV’s access to new TB diagnostics such as Xpert MTB/RIF
The 6th National Scientific Conference on HIV/AIDS
Acknowledgements
• CDC (Atlanta and Vietnam)• VAAC• National Lung Hospital /National TB Program• Hanoi PAC• HCMC PAC• Pham Ngoc Thach Hospital • Participating OPCs
The 6th National Scientific Conference on HIV/AIDS
Thank you !