Haileyesus Getahun, MD, PhD, MPH.Stop TB Department, WHO
Geneva, Switzerland
Tuberculosis among people who inject drugs: urgent actions needed.
IHRA’s 22nd International Conference, 3-7 April, Beirut, Lebanon.
Outline of presentation
• Magnitude of the problem and evidence
• WHO, UNAIDS and UNODC policy framework
• Key recommendations and operational issues
• Challenges
• Conclusion
What is TB?
• One in three are infected with M. tuberculosis
• Risk of TB in PLHIV: 20-40X
• Isoniazid prevents TB in PLHIV
• Drug susceptible TB: curable with <20 USD/patient
• Drug resistant TB MDR: Resistance to INH & R XDR: Resistance to 2nd line
Transmitted by
Coughing
Sneezing
Estimated number of
cases
Estimated number of
deaths
1.3 million*(range, 1.2–1.5 million)
9.4 million(range, 8.9–9.9 million)
0.5 million
All forms of TB(men and women)
Multidrug-resistant TB (MDR-TB)
HIV-associated TB 1.1 million (12%) (range, 1.0–1.2 million)
0.4 million (range, 0.32–0.45 million)
The global burden of TB in 2009
*excluding deaths among HIV+ people
~ 0.15million
All forms of TB(in women)
3.6 million (38%) (range, 3.4–3.8 million)
0.5 million (range, 0.4–0.6 million)
Incidence of TB per 100,000 population
0–24
25–49
50–99
100–299
300 and higher
No estimate availablePrevalence of injecting drug use per 100,000
No reportReported, no estimate >1000500-1000 250-5000-250
Prevalence of HIV among PWID (%)
0-45-910-1920-3940+IDU report, no HIVHIV in PWID, no estimateNo reports
Estimated HIV prevalence in new TB cases (%)
0–45–19
20–4950 and higherNo estimate
Country (yr) Drug used TST + TB diseaseIran (2001)1 Heroin, opium 40% 6.4%USA (2002)2 Heroin, crack 29% NRUSA (2007)3 Crack cocaine 28% NR
TB risk is high in PWUD regardless of HIV
References1.Askarian et al East Mediterr Health J 2001; 7:461–4.2.Howard et al Clin Infect Dis. (2002) 35 (10): 1183-11903.Grimes et al Int J Tuberc Lung Dis 2007; 11:1183–9.
Pre-HIV era studies: 10x more risk of TB in PWUD
Factors associated with tuberculosis as an AIDS-defining disease (Barcelona 1994-2005) Source: Martin V et al J Epidemiol 2011 ;21 (2) :108-113
Risk Group % OR 95%CIAdjusted
OR 95% CI MSM 18.2 1 IDU 40.8 3.10 2.6-3.8 2.58 2.1-3.2 Heterosexual 26.5 1.63 1.3-2.1 1.96 1.5-2.6 Unknown 17.7 0.97 0.6-1.6 1.01 0.6-1.7
TB disease risk is high among PWID
TB, IDU and incarceration linkage
• PLHIV who inject drugs and developed TB have a four fold increased risk of incarceration1
• Up to 74% prisoners injected and up to 94% shared equipment while in prison2
• 78% PWID were incarcerated and 30% injected while in prison3
References1. J Epidemiol 2011 ;21 (2) :108-1132. Lancet Infec Dis 2009;9:57-663. BMC Public Health 2009, 9:492 doi:10.1186/1471-2458-9-492
TB in prison
• 1 in 11 TB cases in high income countries
• 1 in 16 TB cases in mid-low income countries
Prison transmission
23 times more risk of TB disease in prisoners than the general population
PLoS Med 7(12): e1000381. doi:10.1371/journal.pmed.1000381
Table 4 Statistically significant differences in rates of drug resistance among all tuberculosis patients in the civilian and penitentiary sectors.
Civilian sector
(%)Penitentiary sector (%)
RR
(95% CI)
Any resistance 47.2 67.5 1.4 (1.3–1.6)
MDR TB 22.9 40.9 1.8 (1.5–2.2)
MDR TB is common among prisoners
Ref : Dubrovina et al INT J TUBERC LUNG DIS 2008; 12:756–762
Lower survival of TB patients who inject drugs
Table 1. Prevalence of HIV, HBV and HCV among 205 patients with TB in Buenos Aires, Argentina, 2001
Organism No. positive/ no. studied
% Prevalence (95% CI)
HBV 37/187 19.8 (14.3-26.2)
HCV 22/187 11.8 (7.5-17.3)
HIV 35/205 17.1 (12.2-23.9)Source: Pando et al Journal of Medical Microbiology (2008), 57, 190-197
HBV and HCV common among TB patients
The policy guidance
Recommendations
• Multisectoral coordination• TB screening and prevention• HIV testing and prevention• Treatment of TB and co-
morbidities • Integrated service delivery
Functional multisectoral coordinating body
• Composition National AIDS and TB Programs Harm reduction programs Criminal justice system Social care and psychological services Representatives of people who use drugs
• Functions Favorable policy, programme and legislative
environment Promote evidence base practice and programs Develop TB/HIV national strategic plan Define roles and responsibilities of stakeholders
TB screening and isoniazid preventive therapy (IPT)
SettingSen (%)
Spe (%)
Negative Predictive Value (95% CI)
Community 76 61 97.3 (96.9-97.7)
Clinical 89 30 98.3 (97.5-98.8
CD4 < 200 94 22 98.9 (95.8-99.5)
CD4> 200 83 34 96.9 (95.1-98.0)
Symptom based TB screening is sufficient to exclude TB among PLHIV who use drugs and provide at least 6
months IPT
None of current cough, fever, night sweats or weight loss = No TB = IPT
Getahun et al PLoS Medicine 2011
Table 2. Final results of treatment of latent TB in 415 long term drug users who received INH≥7 days
Outcome No (%) Completed treatment correctly 319 (76.9)Abandoned or changed treatment 71 (17.1)Elevation in ALT/AST 3-5X normal 34 (8.2)Hepatotoxicity all 20 (4.8)Hepatotoxicity clinical 6 (1.4)Removed for other reasons 5 (1.2)Source: Fernandez-Villar et al Clinical Infectious Diseases 2003; 36:293–8
IPT is not toxic to people who use drugs
Excessive alcohol consumption (OR 4.2, P=0.002) and underlying liver disease (OR=4.3, P=0.002) are
associated with hepatoxicity
ART reduce TB risk by 54-92% among PLHIV
Lawn et al Lancet Infect Dis 2010;10: 489–98
Co morbidities, including viral hepatitis infection (such as hepatitis B and C), should not contraindicate HIV or TB treatment for people who
use drugs
Integrated TB, HIV and HR services
• Integrated service delivery initiated in 2008 :- TB/HIV/HR services- TB/HR services
• In 2009-2010, 25 TB/HIV sites established
• In one Kiev site in the first 6 months 20 PLHIV on ST were diagnosed with TB All of them CD4 <10 and were started ART All of them completed TB treatment and CD4 >200
• Key factor for success: on site access for TB dx
The example of All Ukrainian Network of PLHIVKonstantin Lezhentsev, TB/HIV CG meeting presentation, Almaty, May 2010.
Key challenges
• Absence of data and lack of ownership Who should collect and communicate data? Who should own the services?
• Structural barriers Lack of collaboration among stakeholders Mandatory hospitalisation of TB patients in CAR and
EE
• Additive toxicities and perception of HCW
• Stigma linked with multiple co-morbidities
• Lack of awareness by activists and advocates
TB/HIV Advocacy guide for HR advocates
• HIT and INPUD with support by WHO, UNAIDS and IHRA
• Based on existing TB/HIV experiences
• Consultation on Sunday 3 April 2011 in Beirut.
• Document will be available in July 2011.
Stronger civil society voice to promote human rights based approach and accountability to the
TB response
Conclusion
Consensus Statement of the Reference Group to the United Nations on HIV and Injecting Drug Use, 2010.
“Addressing TB
among IDUs is a
public health
priority.”
Conclusion
• Reliable global data on TB in people who use drugs and among prisoners urgently needed.
• More TB ownership from prison and harm reduction services and vice versa needed.
• Prompt co-treatment of TB, HIV and other co-morbidities among PWUD save lives.
• Services should be scaled-up in a client friendly manner with due respect to basic human rights
Acknowledgement
• A. Ball• A. Baddeley• L. Blanc • R. Granich• C. Gunneberg• A. Reid• D. Sculier• C. Smyth• A. Verster
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