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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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REFLECTIONS ON

HIV/AIDS AND MDR

PAHO/WHO

Dr. Andrea Luna Heine

Resident/Consultant, USAID/PAHO Training Program

SupraNational Reference Laboratory, Chile


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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


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1. Current Situation

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


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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


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per 100,000 pop. 2001)

< 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


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Growing Tendency of TB Incidence 2001)

(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


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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


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In Africa, more HIV means more TB; Tuberculosis, 2000however, 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


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Impact of HIV on Tuberculosis Tuberculosis, 2000(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


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0 - 0.9 Tuberculosis, 2000

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


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Prevalence of HIV Infection Tuberculosis, 2000among 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


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Prevalence of MDR Tuberculosis, 2000among 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


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2. Evidence Found: Tuberculosis, 2000

Contradictory?

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


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Is there any association between Tuberculosis, 2000HIV 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


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Are hospitals a risk factor for HIV ? Tuberculosis, 2000

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


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How reliable are the publications on this? Tuberculosis, 2000Certain 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.)


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How reliable are the publications on this? Tuberculosis, 2000Certain 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.


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How reliable are the publications on this? Tuberculosis, 2000 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.


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How reliable are the publications on this? Tuberculosis, 2000 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)


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HIV/AIDS Tuberculosis, 2000

High Prevalence of MDR

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


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Lack of Control in the DOTS Strategy Tuberculosis, 2000

HIV/AIDS

High Prevalence of MDR

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



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MDR in New York August 2003(1992–2000)

Source: New York City Department of Health.

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


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3. Coming closer August 2003

to an answer ...

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


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Initial Resistance Study August 2003

(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


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Verifying the Information August 2003

  •  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


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Trends of Initial and Acquired Resistance: August 2003

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


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General Characteristics August 2003

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


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General Characteristics August 2003

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


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Sample Characterization August 2003

  • 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


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  • What Other Chilean Studies Show August 2003

  • 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


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HIV/AIDS August 2003

TB

MDR


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HIV/AIDS August 2003

TB Micobacteria?

Misreported as ‘never treated’?

MDR

TB

DOTS?

Outbreak?


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Summing Up August 2003HIV/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