Controlling TB in the Context of HIV 3 rd Global TB/HIV Working Group Meeting, June 4-6, 2003

1. Controlling TB in the Context of HIV 3rd Global TB/HIV Working Group Meeting, June 4-6, 2003 Montreux, Switzerland Diana Spies Pope, M.S., R.N. Johns Hopkins Center for Tuberculosis Research http://www.hopkins-tb.org/

2. TB impact on a world-wide scale TB Alert

3. Estimated distribution of adults infected with HIV and tuberculosis, 2000 100 000 50 000 400 000 50 000 150 000 SE Asia 2.3 million 450 000 SS Africa 9.5 million 5 000 Global Total: 13 Million World Health Organization

4. DOTS and HIV-related TB • DOTS is a critically important strategy for effective management of TB • DOTS increases cure rates, reduces mortality and prevents emergence of drug resistance • In the setting of HIV prevalence, DOTS alone is not sufficient to control TB incidence

5. Population dynamics of TB Latent TB Active TB Primary TB Uninfected/susceptible

6. Population dynamics of TB in a setting of high HIV prevalence Latent TB HIV+ Active TB HIV+ Primary TB Uninfected/susceptible HIV+

7. Strategies for control of TB in a setting of high HIV prevalence Latent TB HIV+ Active TB HIV+ DOTS Primary TB Uninfected/susceptible HIV+

8. Mission To organize, implement and evaluate novel public health strategies to reduce morbidity and mortality from tuberculosis in populations with high rates of HIV and TB co-infection.

9. Major aims of CREATE proposal • Devise, implement and evaluate novel public health strategies for TB/HIV in high burden areas • Conduct a series of community level trials assessing and comparing impact of interventions • Document reductions in TB incidence/mortality • Develop new global policies for TB/HIV control through evidence-based advocacy

10. Controlling TB in areas with high HIV prevalence • Prevent HIV transmission • Expand and strengthen DOTS • Active and Intensified case-finding • Contact evaluation • For active disease (ACF)  treat • For latent infection  preventive therapy • Treat HIV infection with ARVs

11. Innovative approaches to control HIV/TB • Active and Intensified case finding: Kenya, Malawi, South Africa, Uganda, Zambia • Mass preventive therapy (gold mines) • Targeted preventive therapy in high prevalence communities, cohorts, or households • Impact of ARVs on TB incidence • Impact of IPT on TB in setting of HAART

12. Active case finding: HIV and TB screening in Cite Soleil, Haiti • HIV counseling and testing services, TB skin tests and chest radiographs offered by outreach workers • 10,611 adults screened • 1629 (15%) HIV+ • Active TB found in 6% of HIV+ and 2% of HIV– • 70% of HIV+ also PPD Positive • >75% received preventive therapy Desormeaux et al., Bull Pan Am Health Organ 1996;30:1-8

13. Active case finding: HIV+ women in pMTCT program in Soweto, South Africa • 438 HIV+ (>95% women who delivered infants in nevirapine demonstration project) • Intervention: PPD testing and TB evaluation • 73% (318) returned for TST reading • 49% (157) PPD+ (≥ 5mm) • 13 with active TB (4-8% of PPD+, 2-4% total) • 6 with AFB culture+ MTB • 5 Sm +, and 2 Sn & Sx of TB - response to Rx High prevalence of unsuspected, active TB in women with access to clinical services Nachega et al., AIDS, in press

14. Contact investigations & screening in high risk settings ACF and opportunity for preventive Rx • HIV + • Contacts • Found in VCT sites • Found in MCH settings • Children <5 • Adolescents? • Congregate living (prisons, dormitories) • Everyone?

15. Rates of TB during and after treatment with INH or placebo, randomized by household G. Comstock, USPHS Bethel, Alaska TrialAdv Tbc Res 1969

16. Rates of TB in mines with or without mass INH treatment, 1966 Smit, Proc Mine Med Off Assoc, 1968

17. HAART and TB: Key points • HAART reduces risk of TB by >80% • Patients on HAART still have risk of developing TB (3%/year for CD4 <200) • HAART guidelines for developing countries miss large proportion of those who will develop TB (CD4>200) • IPT may prolong survival even in those with access to HAART

18. Effect of HAART on incidence of TB in South Africa Badri et al., Lancet 2002;359:2059-64

19. IPT with ARVs: Brazil • National program - free HAART for all in need • Deaths, hospitalization and some OI’s declined since introduction of HAART in Brazil • Reduction in TB suggested in some studies • TB still leading OI in HIV + • Rio de Janeiro has strong TB program with rapidly expanding DOTS • IPT not routinely used for HIV + (or HIV 1-)

20. Phased implementation trial:Recruitment of 3 clinics with >500 pts every 3 months TB incidence pre-IPT TB incidence post-IPT

21. Controlling TB in HIV-Endemic and Other High Incidence Areas Requires… • Reassessment of traditional dogma for TB control • Development of new tools and technologies • Joint approaches with HIV control programs • Novel strategies with limited public health precedent

22. Johns Hopkins University, Baltimore, USA • Aurum Health Research Unit, Welkom, SA • London School of Hygiene and Tropical Medicine, UK • Municipal Health Secretariat, Rio de Janeiro, Brazil • Rakai Project, Viral Institute, Rakai,Uganda • University of Alabama at Birmingham, USA • US Centers for Disease Control and Prevention, Kenya • World Health Organisation