TB/HIV Research Approaches and Challenges

1. TB/HIV ResearchApproaches and Challenges Naomi Bock, MD Global AIDS Program Centers for Disease Control and Prevention February 14, 2005

2. There is a clear complimentarity and inter-relationship between monitoring and evaluation (M&E), some specific surveillance activities and operational research. All derive “strategic information”, new knowledge and data that will make up the evidence base on ART delivery in resource-limited settings.

3. Approaches (1) D.C. State of Georgia, USA

4. InformationasIntervention AFIX Dini et al, J Pub Health Manage Prac, 1996

5. Assessment Feedback Incentive eXchange AFIX Dini et al, J Pub Health Manage Prac, 1996

6. Vaccination Series Completion Rates Georgia Compared with U.S. LeBaron et al, JAMA, 1997

7. Approaches (2) Eastern Europe & Central Asia 1.2 – 1.8 million Western Europe 520 000 – 680 000 North America 790 000 – 1.2 million East Asia & Pacific 700 000 – 1.3 million North Africa & Middle East 470 000 – 730 000 Caribbean 350 000 – 590 000 South & South-East Asia 4.6 – 8.2 million Sub-Saharan Africa 25.0 – 28.2 million Latin America 1.3 – 1.9 million Australia & New Zealand 12 000 – 18 000

8. NNRTI Response Study Observational Study of Treatment Effectiveness and Resistance Patterns among Women Initiating Treatment with Non-nucleoside Reverse-transcriptase Inhibitor-based HAART after Previous Single Dose Nevirapine (SD NVP) in Pregnancy Welcome to the NNRTI Response Study Website. The Epidemiology Branch of the Division of HIV/AIDS Prevention and the Care and Treatment Branch of the Global AIDS Program (GAP), U.S. Centers for Disease Control and Prevention in Atlanta are jointly coordinating this study to examine the response to highly active antiretroviral therapy (HAART) that includes nevirapine (NVP) among women who have been exposed to prior single-dose (SD) NVP as compared to those who have not.  This is a prospective observational study consistent with the goal to conduct clinically applicable operational research that is expected to directly inform program implementation. This study will be conducted in at least 2 sites, including Zambia and in Thailand, under the direction of the Principal Investigators listed.  The sites where the study will be conducted are providing non-nucleoside reverse transcriptase inhibitors (NNRTI)-based HAART to persons attending their clinics.  Some of the women attending these clinics have received SD-NVP for PMTCT in the past and others have not.  This study intends to use the opportunity that has been presented at the early stage of a period of rapid expansion of antiretroviral therapy in resource-constrained settings to generate data to address the important question of response to NNRTI-based HAART therapy among women who have received SD-NVP for PMTCT as compared to women who have not. HOME CALENDAR CONTACT US PROTOCOL PROJECTMANUAL FORMS CODE BOOKS PROGRESS REPORTS

9. † International Union Against Tuberculosisand Lung Disease Study A Report of a Controlled Clinical Trial of Two Durations of Chemotherapy for the Treatment of Tuberculosis Amina Jindani, Andrew Nunn, Donald Enarson For the Clinical Trials Programme Investigators

10. The TB Trials Consortium (TBTC) • Funded since 1998 by the Division of TB Elimination, CDC • 28 clinical sites worldwide • Links to local TB control programs • TBTC Mission: “… to conduct programmatically relevant clinical, laboratory, and epidemiologic research concerning the diagnosis, clinical management, and prevention of tuberculosis infection and disease.”

11. 2004 Distribution of TB Trials Consortium Clinical Sites Barcelona Kampala 28 clinical sites worldwide CDC Administrative, Statistical, and Data Management Center Rio de Janeiro Durban

12. World Health Organization WHO> WHO sites Home About WHO Countries Health Topics Publications Research tools WHO sites • Database on global MDR-TB research activities • Background • Currently, there is a lack of evidence available to develop policy • recommendations for the management of multidrug-resistant tuberculosis • (MDR-TB) in low- and middle-income settings. As a result, WHO and • partners developed the DOTS-Plus strategy which is currently being tested • through pilot projects and operational research activities. In order to • stimulate global MDR-TB research activities the Stop TB Working Group on • DOTS-Plus for MDR-TB has developed a prioritised research agenda for DOTS-Plus. • A prioritised research agenda for DOTS-Plus for multidrug-resistant • tuberculosis (MDR-TB) [pdf 51kb]The Stop TB Working Group on DOTS-Plus for MDR-TB. International • Journal of Tuberculosis and Lung Disease 2003, 7(5): 410-414. • In addition, a database on global MDR-TB research activities has been created • with the following purpose: http://www.who.int/tb_search/

13. World Health Organization WHO> WHO sites Home About WHO Countries Health Topics Publications Research tools WHO sites DOTS Plus and the Green Light Committee WHAT IS DOTS-PLUS? Based upon DOTS, DOTS-Plus is a comprehensive management strategy under development and testing that includes the five tenets of the DOTS strategy. DOTS-Plus takes into account specific issues (such as the use of second-line anti-TB drugs) that need to be addressed in areas where there is high prevalence of MDR-TB. Thus, DOTS-Plus works as a supplement to the standard DOTS strategy. By definition, it is impossible to conduct DOTS-Plus in an area without having an effective DOTS-based TB control programme in place.... WHAT IS THE GREEN LIGHT COMMITTEE? http://www.who.int/tb/dots/dotsplus/management/en/

14. Feedback loop Policy definition/revision Evaluation and operations research Program implementation

15. Challenges • Local involvement • Protection of human subjects

16. Local Involvement • National / District / Local programs involved in planning as well as implementation • Strengthen TB programs • Avoid redirecting scarce resources • Include the community of people with TB and HIV

17. Local Involvement • National / District / Local programs involved in planning as well as implementation • Strengthen TB programs • Avoid redirecting scarce resources • Include the community of people with TB and HIV • HIV programs involved in planning, implementation, evaluation, policy

18. Feedback loop Policy definition/revision Evaluation and operations research Program implementation

19. Feedback loop Policy definition/revision Evaluation and operations research Program implementation

20. Challenges • Local Involvement • Protection of human subjects

21. Declaration of Helsinki “Concern for the interests of the subject must always prevail over the interests of science and society.” 1975 revision

22. Tuskegee Study of Untreated Syphilis • Conducted • To study the natural history of untreated latent syphilis • By US Public Health Service, with support from the Milbank Memorial Fund • Beginning in 1932

24. Non-therapeutic lumbar puncture

26. Tuskegee Syphilis Ad Hoc Panel, 1973 • No informed consent • Vulnerable population • Undue inducements - burial costs • Participants not informed when penicillin therapy became available in the 1950s • Participants systematically blocked from receiving treatment

27. In 1997, surviving participants of the Tuskegee Syphilis Study and their families gathered at the White House to witness the President's apology on behalf of the United States government

28. Proposed Roles of WHO • Database of research studies • GLC approach to those programs interested in participating in research • Program strengthening with partners • DTBE/CDC and Union operational research courses

29. Proposed Roles of WHO (2) • Facilitating human resource expansion • Identifying training grants which fund masters or doctoral students for in-country research • Stimulating donors to create more such programs • “Club” of National/District/local programs participating in research at program level, including multi-centre research