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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, DMSc Kuala Lumpur 2 nd July 2013. Proportions of adult TB cases attributable to HIV in 2000. Corbett , Arch Intern Med 2003.

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Integration of TB and HIV: marked reductions in TB incidence after introduction of ART

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  1. Integration of TB and HIV: marked reductions in TB incidence after introduction of ART Ole Kirk, MD, DMSc Kuala Lumpur 2nd July 2013

  2. Proportions of adult TB cases attributable to HIV in 2000 Corbett, Arch Intern Med 2003

  3. Increasing TB incidence due to HIV in the early 1990’s in Spain TB of all AIDS cases: Spain (all) 1996: 39% Catalonia 1994: 37% VallMayans, AIDS 1997 Castilla, AIDS 1997

  4. Marked CD4 gradient in TB incidences in the pre-cARTera incidence (events /1000 PYFU) Current CD4: • <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

  5. Decline in TB incidenceswhencARTwasintroduced 15 10 5 Kirk, AJRCCM 2000; modified

  6. Decline in TB incidence due to cART and CD4 increases Current CD4: 50 40 30 20 10 Kirk, AJRCCM 2000

  7. Effect of cARTdurationon TB incidence Incidence (event/1000 PYFU) MonthssincecART initiation Girardi, CID 2005

  8. TB incidencesfollowingcART initiation - influence of CD4 level CD4 <50/mm3 CD4 50-199/mm3 CD4 200-349/mm3 CD4 >350/mm3 Lodi, Thorax 2013

  9. TB incidencesfollowingcART initiation - pronouncedeffect at low CD4 CD4 <50/mm3 CD4 50-199/mm3 CD4 <50/mm3 CD4 200-349/mm3 CD4 >350/mm3 Lodi, Thorax 2013

  10. TB incidenceremainshigh in Eastern Europe Kruk, AIDS 2011

  11. Mortality differences in Europe after a TB diagnosis 33% 8-14% Podlekareva, AIDS 2009

  12. HIV+ peoplewith TB in Eastern Europe die from TB Podlekareva, ERJ 2013 (in press)

  13. Conclusions • Marked decreases in TB incidences in Western Europe after an intense scale-up of cART • Pronouncedeffect of cARTwhenstarted at low CD4 count, whereas the effectwas minimal at higher CD4 levels • Usage of cARTwasassociatedwith a lowerrisk of TB-relateddeath in HIV+ peoplealreadydiagnosedwith TB

  14. 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

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