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REFLECTIONS ON HIV/AIDS AND MDR. PAHO/WHO. Dr. Andrea Luna Heine Resident/Consultant, USAID/PAHO Training Program SupraNational Reference Laboratory, Chile. 1. Current Situation 2. Evidence Found: Conclusive? 3. Getting Closer to an Answer. 1. Current Situation.

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slide1

REFLECTIONS ON

HIV/AIDS AND MDR

PAHO/WHO

Dr. Andrea Luna Heine

Resident/Consultant, USAID/PAHO Training Program

SupraNational Reference Laboratory, Chile

slide2

1. Current Situation

2. Evidence Found: Conclusive?

3. Getting Closer to an Answer

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide3

1. Current Situation

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide4

Estimated Total Population Living with HIV/AIDS (end of 2001)

Eastern Europe and Central Asia

1 million

Western Europe

560,000

North America

940,000

East Asia and Pacific

1 million

North Africa and Mideast

440,000

Central America

420,000

South East Asia

6.1 million

South America

1.4 million

Sub-Saharan Africa

28.1 million

Australia

15,000

Total: 40 million

slide5

per 100,000 pop.

< 10

10–24

25–49

50–99

100–299

300+

No estimate

The highest estimated rates for TB are found in Africa

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide6

Growing Tendency of TB Incidence

(African and Eastern European Countries)

200

180

Africa, low HIV

Africa, high HIV

160

Post-communist countries

140

120

Notification Rates per 100,000

100

80

60

40

20

0

1980

1985

1990

1995

2000

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide7

Estimated Distribution of Adults Infected with HIV and Tuberculosis, 2000

100,000

50,000

50,000

400,000

150,000

South East Asia

2.3 million

Sub-Saharan

Africa 9.5 million

450,000

5,000

Global Total : 13 million

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

in africa more hiv means more tb however the mdr rate is relatively low
In Africa, more HIV means more TB; however, the MDR rate is relatively low.

Zimbabwe

MDR=1.9%

Malawi

MDR=0.3%

Kenya

MDR=0.5%

Tanzania

MDR=0.9%

Ivory Coast

MDR=5.3%

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

impact of hiv on tuberculosis usa 1980 1992
Impact of HIV on Tuberculosis(USA, 1980–1992)

Cases (thousands)

35

30

observed

25

57,000 more cases

20

15

foreseen

10

5

0

79

80

81

82

83

84

85

86

87

87

88

89

90

91

92

93

Year

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide10

0 - 0.9

1 - 2.9

3 - 4.9

5 - 6.9

7 +

No estimate

Estimated Percentage of MDR among New TB Cases, 2000

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

prevalence of hiv infection among tb patients selected countries region of the americas 2001
Prevalence of HIV Infectionamong TB Patients (Selected Countries, Region of the Americas, 2001)

NY 199726%

English Caribbean (2000)*:

BAH 38%

BEL 14%

GUY 32.4%

JAM 16%

SUR 14%

TRT 32%

DOR 1997 17%

HON 20018.0%

MEX 1990-1994 3.1%

GUT20008.0%

ELS 19962.8%

NIC1999 0.8%

Rio de Janeiro BRA1995-199835.6%

Sources: Reports from National TB-Control Programs.

* Caribbean Epidemiology Centre (CAREC).

ARG 1995 2.2%

URU19970.7%

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide12

Prevalence of MDRamong Cases Never Treated(Region of the Americas, 1994–2002)

CAN 1.2%

-

USA 1.2%

DOR 6.6%

CUB 0.3%

MEX: 3 states 2.4%

Puerto Rico 2.5%

GUT 0.7%

VEN 0.3%

HON 1.8%

ELS 0.3%

NIC 1.2%

COL 1.47%

ECU 6.6%

BRA 0.9%

PER

BOL

3.0%

1.2%

No data

>= 3%

-

CHI

ARG

0.6%

< 3%

-

0.9%

URU

=< 1%

-

0.01%

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide13

2. Evidence Found:

Contradictory?

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

is there any association between hiv and tb mdr
Is there any association between HIV and TB/MDR ?

% of resistance to one or more drugs

Gordin

1996

Bercion

1995

Ash

1996

Dosso

1999

Spellman

1997

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide15

Are hospitals a risk factor for HIV ?

10

Odds Ratio (95%CL)

1

0.1

Espinal 2001

Yoshiyama

Kenyon 1999

Kenyon 1999

2001

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

how reliable are the publications on this certain methodological errors crop up frequently

How reliable are the publications on this?Certain methodological errors crop up frequently.

Non-representative samples

  • Samples not randomized.
    • Methodological defects in sample design (descriptive estimates, small size)
  • Subproducts

(Designed with other objectives in mind.)

how reliable are the publications on this certain methodological errors crop up frequently17

How reliable are the publications on this? Certain methodological errors crop up frequently.

Biases

  • Information Bias
    • Fails to report previous treatment.
    • Fails to report contacts (MDR).
  • Memory Bias
    • Fails to remember medication given (incorrectly reported as \'never treated\').
  • Selection Bias
    • Serious or uncompensated percentages.
    • Hospital reports.
    • Informed consent.
how reliable are the publications on this certain methodological errors crop up frequently18

How reliable are the publications on this? Certain methodological errors crop up frequently.

Factors Creating Confusion

  • No DOTS
    • Flexibility in observed treatment.
    • Irregularity in treatment.
  • Exposure to MDR Strains
    • Less time in hospitals with a greater probability of MDR contact.
how reliable are the publications on this certain methodological errors crop up frequently19

How reliable are the publications on this? Certain methodological errors crop up frequently.

  • Non-TB micobacteria
  • Late diagnosis

Diagnosis

Existence of outbreaks?

  • Differentiated behavior
  • Outbreaks?
    • Can become generalized among the general population (Cluster: RFLP)
slide20

HIV/AIDS

High Prevalence of MDR

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide21

Lack of Control in the DOTS Strategy

HIV/AIDS

High Prevalence of MDR

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide23

MDR in New York(1992–2000)

Source: New York City Department of Health.

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide24

3. Coming closer

to an answer ...

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide25

Initial Resistance Study

(Chile, 2001)

  • Samples input 939 (737)
  • Samples useful for evaluation 867
  • Discarded samples 70 (7.5%)
    • 3.2 % due to false report of \'never treated\' (30)
    •  1.4 % due to non-TB micobacteria (13)
    •  2.9% for technical reasons (19 with no data y 8 contaminated)

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide26

Verifying the Information

  •  Initial survey.
  •  Cross-referencing national TB databases.
  • ENO (EX-RMC14) Epidemiology
  • Registered monthly lab cases ISP
  • Dynamic monthly RNTBC Nursing
  • Review of 100% of the files with >= 1 resistance.
  • Review of a variable percentage of files from sensitive patients x health service from 20% to 100%.
  •  Cross-referencing CONASIDA data on HIV/AIDS.

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide27

Trends of Initial and Acquired Resistance:

Global-Resistance and Multi-Resistance Forms

(1971–2001)

GlobalInitialResistance

AcquiredInitialResistance

InitialMulti-Resistance

AcquiredMulti-Resistance

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide28

General Characteristics

Analysis of the Impact of HIV/AIDS and the Immigrant Population

  • There is no difference in the characterization of the population as regards sex and age among the resistant and non-resistant population.
  • The population profile is not affected by populations with HIV/AIDS and migrants; but this is the case if there is change within these populations vis-à-vis the national population.

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide29

General Characteristics

Analysis of the Impact of HIV/AIDS and the Immigrant Population

  • The population co-infected with HIV/AIDS in this sample was 3.4%.
  • Neither of the two subpopulations affects the national resistance profile.

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide30

Sample Characterization

  • Regarding HIV/AIDS
    • Patients with HIV/AIDS: 3.3% of all \'never-treated\' TB cases.
    • Average age, 37.2 MD 37, 80% of the population is male.
    • 1.1% of the patients are MDR (0.7 national MDR).
  • Regarding being an immigrant
    • Foreign patients = 2.3% of TB cases \'never treated\'.
    • Average age, 33.5 MD 29.5; 60% are women.
    • 1.1% of the patients are MDR.

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide31

What Other Chilean Studies Show

  • HIV patients act as an outbreak.
    • 2.4% are MDR among \'never treated\' (‘naive’) TB-HIV/AIDS patients (national estimate: 0.7%)
    • 19.8% are MDR among previously treated TB-HIV/AIDS patients (national estimate: 20%)

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

slide33

HIV/AIDS

TB Micobacteria?

Misreported as ‘never treated’?

MDR

TB

DOTS?

Outbreak?

summing up hiv aids and mdr tb
Summing UpHIV/AIDS and MDR TB …
  • The global evidence available (Africa, USA, etc.), as well as Regional experiences (Chile), do not indicate any causal association.
  • HIV, however, can be a factor interacting in the generation of MDR TB, above all in the presence of poor tuberculosis control and insufficient biosafety measures.
  • The lack of compliance with strictly supervised anti-TB treatment, as well as exposure to other MDR TB patients, constitute risk factors for drug resistance among this population group.

Workshop on TB/HIV Co-Infection, San Pedro Sula, Honduras, August 2003

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