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HIV/TB Integration in a Network of Voluntary Counseling/Testing Centers in HAITI

HIV/TB Integration in a Network of Voluntary Counseling/Testing Centers in HAITI. Reynold Grand’Pierre MD , Marie Suze Jacquet MD, Jean W. Pape MD PEPFAR Meeting Kigali, Rwanda June 16, 2007. Timeline of HIV Disease in Haiti Before ART: Most important OIs.

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HIV/TB Integration in a Network of Voluntary Counseling/Testing Centers in HAITI

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  1. HIV/TB Integration in a Network of Voluntary Counseling/Testing Centers in HAITI Reynold Grand’Pierre MD, Marie Suze Jacquet MD, Jean W. Pape MD PEPFAR Meeting Kigali, Rwanda June 16, 2007

  2. Timeline of HIV Disease in Haiti Before ART:Most important OIs Pulmonary TB : most common pre-AIDS manifestation occurring in 40% of the cohort by 6 years Most common AIDS illness: wasting syndrome, candida esophagitis, coccidia diarrhea Leading causes of death : wasting syndrome, TB, crytococcal meningitis, toxoplasmosis Deschamps MM et al. AIDS. 2000, 14:2515-2521

  3. Cornell-GHESKIO VCT model with integrated services Post-HIV exposure Counseling and HAART STI Management Pre-test Counseling HIV, Syphilis, Tuberculosis, Malaria Post-Test Counseling Reproductive Health Services (family planning and prenatal care) HIV+ women Prevention HIV MTCT with HAART Same day TB screening / Rx / Px • Care to HIV infected individual / affected family • OI Rx/Px • HAART for AIDS or CD4 count  200 • Nutritional support • Psychosocial support Rx = Treatment Px = Prophylaxis Peck R, Fitzgerald D, Liautaud B et al: JAIDS:33;470-475, 2003

  4. NationalPlan for Expansion of Care and Prevention 2005-2006 GHESKIO Centers PIH “Zanmi la sante”

  5. Screening for TB at HIV VCT Centers • Study to evaluate risk of having TB among clients with cough seeking HIV testing at voluntary counseling and testing centers (VCTs). • Active TB was diagnosed in: • 30% of all VCT clients presenting with cough • Essential to offer same day screeningfor TB for persons with cough at HIV VCT centers • Patients with TB and cough can be rapidly identified for: • Treatment and • Prevention of TB transmission to immuno-compromised patients in waiting rooms • Patients dually infected with TB and HIV can be placed on isoniazid prophylaxis to prevent active TB Burgess A et al, AIDS:15: 1875-1879 2001

  6. Screening of adults with cough for TB at GHESKIO VCT • 30% of all with cough have active TB • 55% of active TB cases are HIV+

  7. HIV seroprevalence in TB and non-TB Adult Patients in MOH-GHESKIO Network in 2006

  8. Tuberculosis prevention in persons co-infected with HIV and TB Rate of active tuberculosis cases per 100 person-years Placebo Intervention Author/Place/Date Pape et al/Haiti/1993 INH, X 1 year 10 1.7 Markowitz et al/USA/1997 INH, X 6 mo 4.7 1.6 Whalen et al/Uganda/1997 INH, X 6 mo 3.41 1.08 INH+RIF, X 3 mo 3.41 1.32 INH+RIF+PZA, X 3 mo 3.41 1.73 Halsey et al/Haiti/1999 INH, 2X/week, X 6 mo - 1.0 RIF +PZA , X 8 weeks - 3.7 INH = Isoniasid ;RIF = Rifampin; PZA = Pyrazinamide

  9. Effect of preventive INH on the incidenceof active and progression of HIV infection Pape JW et al: The Lancet 342: 1993

  10. MDR-TB et VIH In collaboration with Institut Pasteur de Guadeloupe 330 strains of mycobacterium tuberculosis during a 2 year period Joseph, P et al, AIDS 2006, 20:415-418

  11. Outcome of integration of HIV and TB From January 2005 to December 2006 in the MOH-GHESKIO network: • At VCT centers: • 9199 HIV-infected patients were evaluated for TB; • 2395 (26%)of them received care for TB • 2126 patients HIV positive received INH prophylaxis • 3768 patients with tuberculosis were tested for HIV; • 1213 (32%) of them were HIV positive

  12. HIV/TB Challenges for Haiti • Interactions HIV/TB • HIV rate is 2-4 X higher in TB patients • Risk of developing active TB is 10X higher in HIV+. • INH prophylaxis and ART are both effective to prevent active TB in HIV+ • TB diagnosis: majority of TB patients are smear negative. Must do CXR • Most TB centers are staffed by nurses and auxiliary nurses • ART and TB therapyis complex • Preferable not to start HIV and TB therapy at the same time to avoid IRS • High toxicity, mortality; abandon rate, recurrence rate • MDRTB: higher association with HIV+ • Necessity to develop joint HIV/TB national programs 1) Necessity to screen for HIV in all TB centers and 2) Screen for TB at VCT centers. • HIV+ and PPD+ should have a CXR and sputum smear to rule out active TB • Place on TB therapy those with active TB and on INH those who do not have active TB • HIV+ should receive INH + RIF during entire duration of therapy 3) Develop joint ART/TB training for care of HIV + patients requiring both 4) Need to develop new category of medical staff: Physician assistant 5) Must develop effective referral system between HIV and TB centers 6) Need to have nationwide survey on importance of MDRTB and new centers to care for MDRTB

  13. Perspectives • Complete integration between the national HIV and TB programs is necessary to curb both epidemics. • With PEPFAR support, plan to create at a public TB site (Siguenau): • Unit for HIV/TB management • Unit for MDRTB treatment

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