1 / 21

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 Associate Professor of Epidemiology , Columbia University. Key differences in HIV vs TB. TB. HIV. No public health mandate for treatment

javier
Download Presentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 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

  2. 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

  3. 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

  4. May DOT for ARV increase drug pressure to a critical level where the risk of drug resistance is subsequently highest?

  5. But where does Directly Observed Therapy for Tuberculosis stand?

  6. Universal paradigm? • One size-fits-all or custom-made? • Home or clinic/hospital based? • Family member or community worker?

  7. Cochrane Review of DOT for Tuberculosis: Impact on Cure Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007

  8. 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

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

  10. 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

  11. 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

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

  13. 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

  14. 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.

  15. 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)

  16. But what groups of patients? • All • New patients • Low motivational state and Late-stage disease (Bangsberg) • Implications (and what is it in TB?)

  17. In Tuberculosis, the priority for treatment is the most contagious form • However, virologic tool for adherence

  18. Social contextts • The epidemics do cross but not perfectly • Impact of private sector • As HIV moves to primary care, what impact on supervision?

  19. Source: Macq J, Torfoss T, Getahun H. et al Patient empowerment in Tuberculosis Control: Reflecting on Past Documented Experiences. 2007

  20. Source: Macq J, Torfoss T, Getahun H. et al Patient empowerment in Tuberculosis Control: Reflecting on Past Documented Experiences. 2007

  21. 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

More Related