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    TB and HIV

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    1) TB and HIV epidemics are mutually reinforcing, with HIV increasing susceptibility and accelerating progression of TB while TB is a leading cause of death among people living with HIV. 2) Efforts are being made in Myanmar to strengthen collaboration between HIV and TB programs through activities like increasing HIV testing among TB patients and earlier initiation of antiretroviral treatment for coinfected individuals. 3) Gaps remain including limited implementation of collaborative strategies, insufficient access to diagnosis and treatment, and risks from population movement. Strengthening integrated services and addressing socioeconomic determinants are important to combat the dual epidemic.

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    TB and HIV

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    National Press Foundation
    113 views62 pages
    1) TB and HIV epidemics are mutually reinforcing, with HIV increasing susceptibility and accelerating progression of TB while TB is a leading cause of death among people living with HIV. 2) Efforts are being made in Myanmar to strengthen collaboration between HIV and TB programs through activities like increasing HIV testing among TB patients and earlier initiation of antiretroviral treatment for coinfected individuals. 3) Gaps remain including limited implementation of collaborative strategies, insufficient access to diagnosis and treatment, and risks from population movement. Strengthening integrated services and addressing socioeconomic determinants are important to combat the dual epidemic.

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    By Dr. Philippe Clevenbergh

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    1) TB and HIV epidemics are mutually reinforcing, with HIV increasing susceptibility and accelerating progression of TB while TB is a leading cause of death among people living with HIV. 2) Efforts are being made in Myanmar to strengthen collaboration between HIV and TB programs through activities like increasing HIV testing among TB patients and earlier initiation of antiretroviral treatment for coinfected individuals. 3) Gaps remain including limited implementation of collaborative strategies, insufficient access to diagnosis and treatment, and risks from population movement. Strengthening integrated services and addressing socioeconomic determinants are important to combat the dual epidemic.

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    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    113 views62 pages

    TB and HIV

    Uploaded by

    National Press Foundation
    1) TB and HIV epidemics are mutually reinforcing, with HIV increasing susceptibility and accelerating progression of TB while TB is a leading cause of death among people living with HIV. 2) Efforts are being made in Myanmar to strengthen collaboration between HIV and TB programs through activities like increasing HIV testing among TB patients and earlier initiation of antiretroviral treatment for coinfected individuals. 3) Gaps remain including limited implementation of collaborative strategies, insufficient access to diagnosis and treatment, and risks from population movement. Strengthening integrated services and addressing socioeconomic determinants are important to combat the dual epidemic.

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    of 62

    4th Annual Journalist-to-Journalist Lung Health Training

    Discussion about TB and HIV


    43rd Union World Conference on Lung Health Kuala Lumpur
    Philippe Clevenbergh, MD Head of The Union Office in Myanmar International Union Against Tuberculosis and Lung Disease 14:30-15:45 Tuesday, November 13

    Incidence of primary opportunistic infections in two human immunodeficiency virus-infected French clinical cohorts. Yazdanpanah Y, Chne G, Losina E, Goldie SJ,
    Merchadou LD, Alfandari S, Seage GR 3rd, Sullivan L, Marimoutou C, Paltiel AD, Salamon R, Mouton Y, Freedberg KA. Int J Epidemiol. 2001 Aug; 30 (4): 864-71.

    Mycobacterium tuberculosis was the least common opportunistic infection (< 5.0/100 person-years).
    CONCLUSIONS:

    Geographical differences exist in the incidence of HIV-related opportunistic infections.

    Map of poverty (< 2 USD/day) 2010

    TB HIV interaction for the person


    HIV increases the risk of progression to active TB in both primary TB infection and the reactivation of latent TB
    W/o HIV: 3 to 5% develop active TB in the first 2 years after TB infection With HIV: 73% developed active TB within the first 6 months of TB infection

    W/o HIV: lifetime risk of developing active TB due to reactivation = 8 to 10%


    With HIV: risk = 10% per year

    TB/HIV epidemiology in 2008


    33.4 million PLWH: ~ 30% latent or active TB infection 9.4 million TB cases: 1.4 million (15%) were coinfected with HIV HIV infection is the strongest risk factor for TB. PLWH: 20 to 30 times more likely to develop TB than those without HIV. New TB cases 19 times more likely to be coinfected with HIV than general population

    Top 10 OIs treated in 2011 in the IHC program in Myanmar among HIV-infected patients
    Annual OI: 7015 patients treated Minor mucocutaneous manifestations Oral candidiasis Pulmonary tuberculosis Episodes 1,976 1,578 1,243 % 28% 22% 18%

    76%

    Extrapulmonary tuberculosis
    Herpes Zoster Recurrent upper respiratory tract infect Endemic mycosis Cryptococcosis Unexplained chronic diarrhoea

    549
    256 226 142 145 166

    8%
    4% 3% 2% 2% 2%

    Unexplained prolonged fever

    110
    Health solutions for the poor

    2%
    14

    Individual level
    HIV - Increases the susceptibility to and accelerates progression of TB disease - Atypical presentation and delayed diagnosis of TB - Increase the risk of TB treatment failure and development of MDR and XDR TB - Increases risk of recurrence of TB - TB vaccine contra-indicated in children

    Community level

    TB

    TB - First cause of mortality among HIV infected individuals - Increases HIV replication and accelerates HIV disease - Makes treatment of HIV more complicated (timing and choice of drugs) - Is associated with specific complications after HIV treatment (IRIS)

    HIV - Increase the number of TB cases and the spread of TB disease among HIV-infected patients and within the community - Increase the number of MDR and XDR TB cases - Share similar socio-economic features favoring transmission and affecting similar risk groups

    HIV

    TB - Increased mortality in HIVinfected people - Increased risk of transmission of HIV

    Regional distribution of TB/HIV mirrors HIV, 2011


    HIV
    TB/HIV

    Americas (3%)

    Estimated excess TB cases attributed to the worsening HIV epidemic in the United States from 1985 to 1992.

    Kwan C K , Ernst J D Clin. Microbiol. Rev. 2011;24:351-376

    TB is a leading cause of death among PLHIV


    Studies Cote d Ivore1 USA2 Kenya3 Botswana4 South Africa5 India6 Uganda7 Year of study 1991 1996 1997 1998 2005 2007 2009 PLHIV found with TB (%) 44 33 51 40 79 63 37

    References 1. Lucas et al , 1994 2. Afessa et al, 1998 3. Ranna et al, 2000 4. Ansari et al, 2002 5. Martinson et al, 2007 6. Lanjewar, 2011 7. Cox et al, 2012

    430,000 PLHIV died of TB in 2011 (25% of AIDS deaths)

    HIV-associated TB contributes disproportionately to TB-related deaths.

    Kwan C K , Ernst J D Clin. Microbiol. Rev. 2011;24:351-376

    WHO TB/HIV policy: 12 points policy package


    Establish the mechanism for integrated services (Joint NAP and NTP) Decrease the burden of TB in PLHIV (Three Is and earlier ART) (Primarily NAP) Decrease the burden of HIV in TB patients (Primarily NTP)

    TB/HIV collaborative activities in Myanmar

    HIV testing of TB patients in Africa


    2007 2008 2009 2010 2011

    38%

    47%

    56%

    60%

    69%
    2011 AMRO = 53% EURO = 52% SEARO = 32% WPRO = 25% EMRO = 11% Global = 40%

    HIV testing among TB patients in Myanmar

    HIV rapid test: point of care diagnosis

    11,111th TB patient tested for HIV in Mandalay

    Percentage of TB/VCCT testing among registered TB patients during July, August, September, 2012
    100% 98% 98% 96% 94% 92% 92% 90% 88% 86% 84% 82% 80% 78% 85% 90% 97% 96% 95%

    Mandalay

    Pakokku

    Taunggyi

    Lashio

    Meikhtila

    Myingyan

    Monywa

    Percentage of TB/VCCT testing among registered TB patients

    Health solutions for the poor

    Positivity percent among HIV tested registered TB patients during July, August, September, 2012
    25% 23%

    20% 18% 19% 18%

    15% 15% 14%

    12% 10%

    5%

    0%

    Mandalay

    Pakokku

    Taunggyi

    Lashio

    Meikhtila

    Myingyan

    Monywa

    Positivity percent among HIV tested registered TB patients

    Health solutions for the poor

    HIV
    - Advocacy - New drugs - New tools

    VERSUS

    TB

    New diagnostic tools


    The World Health Organization estimates that one-third, or almost 3 million, of the worlds 8.8 million TB cases are never detected or reported let alone diagnosed, treated, and cured properly.
    Ditiu L. Tackling tuberculosis with an all-inclusive approach. Interview by Sarah Cumberland. Bull World Health Organ. 2011 Mar 1;89(3):1701. Available from: http://www.who.int/bulletin/volumes/89/3/11-040311.pdf. (Accessed 2012 June 28)

    New diagnostic tools in the pipeline

    TB diagnosis using smear microscopy

    TB diagnosis using Chest X ray

    Laboratory Strengthening in Mandalay


    Use of available Tools for TB Diagnosis

    Gene Xpert installed in TB OPD in Mandalay

    Gene Xpert installed in TB OPD in Mandalay

    Gene Xpert installed in TB OPD in Mandalay

    Added diagnosis trough Gene Xpert


    Smear microscopy result # SS+ Previously # SS New treated # SS- not done HIV test result Chest Xray result # UK abnormal

    # GX Q3_2012 MTB+

    Total

    169

    43

    120

    44

    70

    55

    169

    New HIV drugs in the pipeline: 13


    Hopeful: Quad (elvitegravir/cobicistat/tenofovir/FTC), elvitegravir, cobicistat, GS-7340, dolutegravir, 572-Trii (dolutegravir/abacavir/3TC), and Quad variations (using GS-7340 and darunavir). Early days: S/GSK1265744, lersivirine (UK-453061), BMS-986001 (formerly OBP-601), BMS-663068, cenicriviroc (TBR-652), rilpivirine-LA (long-acting injection).

    Trailing: apricitabine, ibalizumab (TMB-355; formerly TNX-355), CMX157, CTP-518.

    New TB drugs in the pipeline: 6

    Advocacy

    The waiting room

    PLWH network

    Mobilization of PATB

    The 3 Is => 4 Is
    Intensive case finding TB => HIV and HIV => TB Infection control Isoniazid preventive therapy Earlier Initiation of antiretroviral drugs

    TB Screening and IPT in TB/HIV burden countries, 2011


    1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0

    Countries represent the top 10 and 72% of global TB/HIV burden

    TB Screening

    IPT

    TB patients tested for HIV (%)


    Africa Global

    Regions other than Africa

    TB patients received ART (%)


    Regions other than Africa Global Africa

    TB/HIV patients Started on ART during July, August, September, 2012: 388 patients
    180 168 160

    140 117

    120

    100

    80

    60

    40 20 20 23 14 18

    14

    14

    0 Mandalay Pakokku Taunggyi Lashio Meikhtila Myingyan Monywa Tharkayta Number of TB patients who have started ART during the reporting period

    Health solutions for the poor

    ART services are still too centralized and too few

    Number of facilities providing TB and ART, 2011

    Integrated HIV Care Sites in Myanmar (Sites of ART programs supported by The Union)
    Sagaing Monywa Yae Sakyo Myaing Pakokku Myingyan

    Lashio

    Mandalay (7 townships)
    Taunggyi Aye Thar Yar Kalaw

    Chauk
    Meikhtila
    Legend
    Saturated IHC site

    Tharketa (Yangon)

    New IHC site proposed to be opened in 2013/ Unsaturated IHC site

    Health solutions for the poor

    Service delivery points: - Mandalay - MGH ( 3 units + NAP) - MCH (300 + 550 bedded H) - MTH - CWH - UMTBC - 7 TSHC - Pakokku - PGH - Lashio - LGH - Taunggyi - SST - MCH - Monywa - MGH - Myekthila - MGH - Myinchan - MGH - Tarketha Total: 20 SDP

    Health solutions for the poor

    TB/HIV gaps in Myanmar


    Limited interactions between NAP and NTP TB/HIV technical strategic group pending Limited coverage for TB/HIV collaborative activities and implementation of the 4Is Limited access to ARVs Limited access to MDR TB treatment Unforeseeable risks of transmission of both diseases due to migrations accompanying economic boom

    Conclusion
    TB and HIV epidemics are working hand in hand and mutually enhancing each other magnitude and impact at the individual and community level TB/HIV co-epidemic can be addressed only as a single common global solution Structural and socio-economic changes are required for both diseases Both programs have to learn from each other in order to be successful

    Sources
    Routine data collection from the Integrated HIV Care, The Union Office in Myanmar HIV and Tuberculosis: a Deadly Human Syndemic. Candice K. Kwan and Joel D. Ernst. Clin. Microbiol. Rev. April 2011 vol. 24 no. 2 351-376 Global response to TB/HIV: experiences and challenges. GFATM HIV and TB Disease Committees Meeting, Oct 22, 2012. Haileyesus Getahun. Stop TB Department. World Health Organisation, Geneva. TB/HIV Activist Toolkit, TAG, Treatment Action Group http://www.treatmentactiongroup.org/tb/resources/activist-toolkits (last accessed 5/11/12) Pipeline Report. HIV-HCV-TB. TAG, Treatment Action Group http://www.pipelinereport.org/toc/tb-treatment (last accessed 5/11/12)

    Thank you!

    62

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