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HIV/TB Integration in a Network of Voluntary Counseling/Testing Centers in HAITI. Reynold Grand’Pierre MD , Marie Suze Jacquet MD, Jean W. Pape MD PEPFAR Meeting Kigali, Rwanda June 16, 2007. Timeline of HIV Disease in Haiti Before ART: Most important OIs.

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Hiv tb integration in a network of voluntary counseling testing centers in haiti l.jpg

HIV/TB Integration in a Network of Voluntary Counseling/Testing Centers in HAITI

Reynold Grand’Pierre MD, Marie Suze Jacquet MD,

Jean W. Pape MD

PEPFAR Meeting

Kigali, Rwanda

June 16, 2007


Timeline of hiv disease in haiti before art most important ois l.jpg
Timeline of HIV Disease in Haiti Before ART:Most important OIs

Pulmonary TB : most common pre-AIDS manifestation occurring in 40% of the cohort by 6 years

Most common AIDS illness: wasting syndrome, candida esophagitis, coccidia diarrhea

Leading causes of death : wasting syndrome, TB, crytococcal meningitis, toxoplasmosis

Deschamps MM et al. AIDS. 2000, 14:2515-2521


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Cornell-GHESKIO VCT model with integrated services

Post-HIV exposure

Counseling and

HAART

STI Management

Pre-test Counseling

HIV, Syphilis, Tuberculosis, Malaria

Post-Test Counseling

Reproductive

Health Services

(family planning and prenatal care)

HIV+ women

Prevention HIV MTCT with HAART

Same day

TB screening / Rx / Px

  • Care to HIV infected individual / affected family

  • OI Rx/Px

  • HAART for AIDS or CD4 count  200

  • Nutritional support

  • Psychosocial support

Rx = Treatment

Px = Prophylaxis

Peck R, Fitzgerald D, Liautaud B et al: JAIDS:33;470-475, 2003


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NationalPlan for Expansion of Care and Prevention

2005-2006

GHESKIO Centers

PIH “Zanmi la sante”


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Screening for TB at HIV VCT Centers

  • Study to evaluate risk of having TB among clients with cough seeking HIV testing at voluntary counseling and testing centers (VCTs).

  • Active TB was diagnosed in:

    • 30% of all VCT clients presenting with cough

    • Essential to offer same day screeningfor TB for persons with cough at HIV VCT centers

    • Patients with TB and cough can be rapidly identified for:

      • Treatment and

      • Prevention of TB transmission to immuno-compromised patients in waiting rooms

    • Patients dually infected with TB and HIV can be placed on isoniazid prophylaxis to prevent active TB

Burgess A et al, AIDS:15: 1875-1879 2001


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Screening of adults with cough for TB at GHESKIO VCT

  • 30% of all with cough have active TB

  • 55% of active TB cases are HIV+



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Tuberculosis prevention in persons co-infected with HIV and TB

Rate of active tuberculosis

cases per 100 person-years

Placebo Intervention

Author/Place/Date

Pape et al/Haiti/1993

INH, X 1 year 10 1.7

Markowitz et al/USA/1997

INH, X 6 mo 4.7 1.6

Whalen et al/Uganda/1997

INH, X 6 mo 3.41 1.08

INH+RIF, X 3 mo 3.41 1.32

INH+RIF+PZA, X 3 mo 3.41 1.73

Halsey et al/Haiti/1999

INH, 2X/week, X 6 mo - 1.0

RIF +PZA , X 8 weeks - 3.7

INH = Isoniasid ;RIF = Rifampin; PZA = Pyrazinamide


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Effect of preventive INH on the incidence TBof active and progression of HIV infection

Pape JW et al: The Lancet 342: 1993


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MDR-TB et VIH TB

In collaboration with Institut Pasteur de Guadeloupe

330 strains of mycobacterium tuberculosis during a 2 year period

Joseph, P et al, AIDS 2006, 20:415-418


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Outcome of integration of HIV and TB TB

From January 2005 to December 2006 in the MOH-GHESKIO network:

  • At VCT centers:

    • 9199 HIV-infected patients were evaluated for TB;

      • 2395 (26%)of them received care for TB

    • 2126 patients HIV positive received INH prophylaxis

  • 3768 patients with tuberculosis were tested for HIV;

    • 1213 (32%) of them were HIV positive


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HIV/TB Challenges for Haiti TB

  • Interactions HIV/TB

    • HIV rate is 2-4 X higher in TB patients

    • Risk of developing active TB is 10X higher in HIV+.

    • INH prophylaxis and ART are both effective to prevent active TB in HIV+

  • TB diagnosis: majority of TB patients are smear negative. Must do CXR

  • Most TB centers are staffed by nurses and auxiliary nurses

  • ART and TB therapyis complex

    • Preferable not to start HIV and TB therapy at the same time to avoid IRS

    • High toxicity, mortality; abandon rate, recurrence rate

  • MDRTB: higher association with HIV+

  • Necessity to develop joint HIV/TB national programs

    1) Necessity to screen for HIV in all TB centers and

    2) Screen for TB at VCT centers.

    • HIV+ and PPD+ should have a CXR and sputum smear to rule out active TB

      • Place on TB therapy those with active TB and on INH those who do not have active TB

      • HIV+ should receive INH + RIF during entire duration of therapy

        3) Develop joint ART/TB training for care of HIV + patients requiring both

        4) Need to develop new category of medical staff: Physician assistant

        5) Must develop effective referral system between HIV and TB centers

        6) Need to have nationwide survey on importance of MDRTB and new centers to care for MDRTB


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Perspectives TB

  • Complete integration between the national HIV and TB programs is necessary to curb both epidemics.

  • With PEPFAR support, plan to create at a public TB site (Siguenau):

    • Unit for HIV/TB management

    • Unit for MDRTB treatment


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