dot can we learn from tuberculosis in the hiv field
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DOT: Can we learn from tuberculosis in the HIV field?. Moïse Desvarieux , MD PhD Chaire d’Excellence ANR, Inserm UMR S 707 Associate Professor of Epidemiology , Columbia University. Key differences in HIV vs TB. TB. HIV. No public health mandate for treatment

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dot can we learn from tuberculosis in the hiv field

DOT: Can we learn from tuberculosis in the HIV field?

Moïse Desvarieux, MD PhD

Chaire d’Excellence ANR,

Inserm UMR S 707

AssociateProfessor of Epidemiology, Columbia University

key differences in hiv vs tb
Key differences in HIV vs TB

TB

HIV

No public health mandate for treatment

Sometimes for transmission

Not entirely clear, nor as fast

Sexual transmission

Lifelong treatment

Best is once daily

  • DOT is public health mandate
    • Physical to pharm quarantine
    • Therapy leads to non-infectiousness
    • Casual transmission
  • TB treatment 6-12 mo.
  • Twice weekly
biology and infection dynamics are different
Biology and infection dynamics are different

TB

HIV

Short generation time and error-prone reverse transcriptase, rapid emergence of resistance

Important effect of food on bioavailability

  • Long generation time and slow emergence of drug resistance
  • MDR is iatrogenic
  • No substantial effect of food
slide4
May DOT for ARV increase drug pressure to a critical level where the risk of drug resistance is subsequently highest?
universal paradigm
Universal paradigm?
  • One size-fits-all or custom-made?
  • Home or clinic/hospital based?
  • Family member or community worker?
slide7
Cochrane Review of DOT for Tuberculosis:

Impact on Cure

Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007

slide8
Cochrane Review of DOT for Tuberculosis:

Impact on Cure or treatment completion

Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007

slide9
Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007
slide10
Cochrane Review of DOT for Tuberculosis:

Impact of location of administration on cure

Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007

slide11
Cochrane Review of DOT for Tuberculosis:

Impact of location of administration on cure or treatment completion

Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007

slide12
Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007
slide13
Cochrane Review of DOT for Tuberculosis:

Impact of family member versus community health worker

Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007

slide14
Clearly, timing seems to matter in TB…

Source: Kruk ME, Schwalbe NR, Aguiar CA et al Timing of Default From Tuberculosis Treatment: A Systematic Review 2008.

clinical trials of dot for hiv should address
Clinical trials of DOT for HIV should address
  • Retention on therapy, virologic and immunologic outcomes to at least one year
  • Development of drug resistance (in spite of our a priori hypothesis)
  • Cost-effectiveness (time and labor intense)
slide16
But what groups of patients?
    • All
    • New patients
    • Low motivational state and Late-stage disease (Bangsberg)
  • Implications (and what is it in TB?)
slide17
In Tuberculosis, the priority for treatment is the most contagious form
  • However, virologic tool for adherence
social context ts
Social contextts
  • The epidemics do cross but not perfectly
  • Impact of private sector
  • As HIV moves to primary care, what impact on supervision?
slide19
Source: Macq J, Torfoss T, Getahun H. et al Patient empowerment in Tuberculosis Control: Reflecting on Past Documented Experiences. 2007
slide20
Source: Macq J, Torfoss T, Getahun H. et al Patient empowerment in Tuberculosis Control: Reflecting on Past Documented Experiences. 2007
conclusions
Conclusions
  • Yes we can learn from TB experience with DOT
  • But do we really want to learn?
  • What are our intrinsic beliefs
  • Targeting is probably the key
  • Impact of primary care and private sector and the end of exceptionalism
ad