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TB/HIV Update

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TB/HIV Update
TB/HIV Update
Central TB Division
Estimated HIV prevalence in new TB
cases, 2008
National estimate – 4.85% of Incident TB
cases are HIV positive
Proportion of Registered TB patients
who are HIV+, 1q10
<1%
1%-4.9%
5%-9.9%
>10%
Highly Variable!!
RNTCP: HIV status among TB patients registered for DOTS
1Q-2Q 2009 Karnataka State
District
Total TB
patient
s
register
ed for
DOTS
No. known to be tested for
HIV (%)
Of the number tested for HIV, no.
known to be HIV infected (%)
Minimum % HIV
positive among
registered TB
patients
BAGALKOT
1114
913
82%
423
46%
38%
BELGAUM
2544
1812
71%
493
27%
19%
BIJAPUR
1135
790
70%
340
43%
30%
DHARWAD
931
612
66%
116
19%
12%
GADAG
530
332
63%
54
16%
10%
HAVERI
750
577
77%
67
12%
9%
UTTARA_KANNADA
646
359
56%
54
15%
8%
BIDAR
856
649
76%
66
10%
8%
BELLARY
1528
1075
70%
133
12%
9%
GULBARGA
1922
959
50%
152
16%
8%
KOPPAL
877
757
86%
134
18%
15%
RAICHUR
1456
1193
82%
187
16%
13%
34165
24246
71%
3977
KARNATAKA
Source:16%
Central TB Division,12%
2009
Treatment outcomes for HIV-positive and HIV-negative
TB patients, 2006 cohort
The numbers under the bars are the numbers of patients included in the cohort
Treatment Outcomes of HIV positive
and HIV negative TB patients, 4q08
100%
80%
Transfer Out
60%
Default
40%
Failure
Death
20%
Success
0%
HIV+
(N=2034)
HIV(N=141304)
NSP TB Patients
HIV+
(N=5422)
HIV(N=345661)
All TB Patients
After TB diagnosis, delayed ART initiation
associated with higher death rates
Lawn et al, CROI 2007
SIGNIFICANT REDUCTION OF MORTALITY
IN THE EARLY ARM
1.00
Mortality rate**
(95% CI)
0.95
0.90
0.85
0.80
0.75
0.70
0.65
Early
arm
8.28
(6.42 – 10.69)
Late
arm
13.77 (11.20 –
16.93)
** per 100 person-years
0.60
0
50
100
150
200
Time from TB treatment initiation (weeks)
Early arm
Late arm
250
CAMELIA STUDY
ANRS 1295/12160 - CIPRA KH001/10425
EARLY ART INITIATION SIGNIFICANTLY
REDUCES MORTALITY
Mortality rate**
(95% CI)
INTEGRA
TED
5.4
(3.5-7.9)
SEQUEN
TIAL
12.1 (8.0-17.7)
** per 100 person-years
Karim et al, Durban, SOUTH AFRICA
“Nationally, RNTCP should
be able to reverse the
increases in TB burden due
to HIV but, to ensure that
TB mortality is reduced by
50% or more by 2015, HIVinfected TB patients should
be provided with
antiretroviral therapy in
addition to the
recommended treatment
for TB.”
Summary: TB-HIV Interaction in India
• India has the highest burden of TB, and a
high burden of HIV in the world
• Most TB is among persons without HIV;
magnitude variable
• HIV may slow down TB control efforts in
India
– Particularly efforts to reduce mortality
• Enormous need for improved TB-HIV
programme collaboration
Response to TB-HIV
The STOP TB Strategy, 2009 Updated language underlined
1.
Pursue high-quality DOTS expansion and enhancement
a.
b.
c.
d.
e.
2.
3.
4.
5.
6.
Secure political commitment, with adequate and sustained financing
Ensure early case detection, and diagnosis through quality-assured bacteriology
Provide standardised treatment with supervision, and patient support
Ensure effective drug supply and management
Monitor and evaluate performance and impact
Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations
a. “Scale–up” collaborative TB/HIV activities
b.
c.
Scale-up prevention and management of multidrug-resistant TB (MDR-TB)
Address the needs of TB contacts, and poor and vulnerable populations
a.
b.
c.
d.
Help improve health policies, human resources development, financing, supplies, service delivery and
information
Strengthen infection control in health services, other congregate settings and households
Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL)
Adapt approaches from other fields and sectors, and foster action on the social determinants of health
a.
b.
Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches
Promote use of the International Standards for Tuberculosis Care (ISTC)
a.
b.
c.
Pursue advocacy, communication and social mobilization
Foster community participation in TB care, prevention and health promotion
Promote use of the Patients' Charter for Tuberculosis Care
a.
b.
Conduct programme-based operational research, and introduce new tools into practice
Advocate for and participate in research to develop new diagnostics, drugs and vaccines
Contribute to health system strengthening based on primary health care
Engage all care providers
Empower people with TB, and communities through partnership
Enable and promote research
2006/rev. 2009
Evolution of TB-HIV collaborative
activities in India
• 2001–First TBHIV “Joint Action Plan” developed; Basic activities in 6
high-HIV burden states
• 2003- Cross referral piloted in MH and initiated in 6 states
• 2004–Expanded to 8 additional States
• 2005–Joint training modules, surveillance
• 2007–Expanded surveillance, CPT/Routine referral pilot, National
Framework for TB/HIV
• 2008–National Framework revised, all-India implementation begins
with Intensified package in 9 states
• 2009 – National Framework revised, Intensified
package scaled up to include 8 more states
• 2010 – Intensified package launched in 11 states
Intensified TB-HIV
package - Nationwide
coverage by 2012
Implementing
Launched (2009)
Launched (2010)
•
•
Currently 11 states implementing (TN,AP,KA,MH,PD,GA,MZ,MN,NG,GU,DL)
Launched in 7 states (AS,WB,OR,KE,RJ,PN,CH) IN 2009
•
Rolled out in 11 states in 2010 (HR,UK,HP,JH,CG,TR,ArP,ME,SI,MP,UP)
National TB/HIV Framework 2009…1
All States
Intensified Package States
District and State-Level Coordination mechanisms
between NACP and RNTCP
Uniform Intensified TB Case Finding at all ICTCs, ART
Centres, and Community Care Centres with Line-list
and Standard Reporting
Training in basic TB/HIV
Additional training on
module
Intensified TB/HIV
Package
National TB/HIV Framework 2009…2
All States
Intensified Package States
Referral of TB patients for HIVtesting based on HIV risk
factors (selective referral)
Routine referral of all TB
patients for voluntary HIVcounselling and testing
(ISTC 14)
Addition: Decentralized CPT
(ISTC 15)
Linking HIV-infected TB
patients to HIV care and
support, including CPT & ART
Core TB/HIV recording and
reporting from NACO MIS and
RNTCP (PMR)
Addition: Expanded TB/HIV
recording and reporting
(Shared Confidentiality)
All TBHIV Training Modules revised
A new “TBHIV module for ART centre
staff” created
• Intensified TB case finding at ART
centres with standardised R&R
• Rifabutin use among HIV-infected TB
patients receiving Second line ART
or Alternative First line ART
(containing Protease Inhibitors)
approved
• Infection control guidelines for ART
centre setting included
• ART in HIV-infected TB patients –
regimen, timing of initiation, special
situations clarified
International & National Guidelines for ART
in HIV-infected TB patients
Who is eligible?
WHO (2009)
NACO (2009)
ALL, regardless of CD4
ALL Stage 4 (EP-TB,
disseminated, miliary)
CD4<350 (Pulm)
(strong recommendation, low
quality of evidence)
When to start?
Start TB treatment first,
Start TB treatment
followed by ART as soon first, followed by ART
as possible after starting as soon as possible, 2
TB treatment.
weeks after starting TB
(strong rec, moderate evidence)
treatment
What to start?
Use EFV as the NNRTI in
patients starting ART
while on TB treatment.
Use EFV as the NNRTI
in all TB patients
receiving ART
TB/HIV Performance
Number of Registered TB Patients
Trends in Number (%) of registered TB patients
with known HIV status, 4q08-1q10
Unknown HIV status
160,000
Known HIV status
140,000
120,000
66%
100,000
80,000
60,000
40,000
34%
44%
54%
60%
62%
20,000
0
4q08
1q09
2q09
3q09
4q09
1q10
Proportion of TB patients with known HIV
status, States, 1q10
100%
90%
87%
80%
83% 80% 81%
78%
66% 67%
70%
60%
52%
57%
50%
37%
40%
29%
30%
26%
20%
13%
10%
0%
Goa
KA
AP
TN
PD India GU
DL
MH
MN
NG
MZ
AS
Proportion of TB patients
with known HIV Status, 1q10
<49.9%
50%-79.9%
>80%
Proportion of Registered TB
patients who are HIV+, 1q10
<1%
1%-4.9%
5%-9.9%
>10%
Number (%) of HIV+ TB patients receiving
CPT during TB treatment, 4q08-2q09
By quarter of TB registration
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
85%
68%
4q08
74%
1q09
Number of HIV+TB patients receiving CPT
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2q09
% of HIV+TB patients receiving CPT
Number (%) of HIV+ TB patients receiving
ART during TB treatment, 4q08-2q09
By quarter of TB registration
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
43%
47%
50%
40%
41%
30%
20%
10%
0%
4q08
1q09
Number of HIV+TB patients receiving ART
2q09
% of HIV+TB patients receiving ART
Trends in Number of TB suspects referred
from ICTC to RNTCP 2006–2009
350000
6.1%
300000
5.2%
250000
200000
7.0%
6.0%
5.0%
3.9%
4.0%
3.5%
150000
3.0%
100000
2.0%
50000
1.0%
0
0.0%
2006
2007
No. TB suspects referred
2008
2009
% of ICTC Clients referred
Trends in TB case detection from ICTC to RNTCP
referrals, 2006–2009 (till September)
40000
35000
77%
82%
81%
84%
30000
25000
20000
15000
10000
5000
0
2006
2007
2008
No. TB cases diagnosed from ICTC referrals
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2009
% of TB cases put on DOTS
Next Steps – 2010-15
• Intensified TB/HIV package - Nationwide coverage by 2012
– Provider-initiated HIV testing for all TB patients
– Immediate and accountable linkage of HIV-infected TB patients to
NACP for HIV care and treatment
• Intensified TB case finding and reporting – Consolidation in
all HIV care settings
• Completed clinical and operational research on IPT for
TB/HIV with policy decisions
• Implementation of airborne infection control measures
• HIV Surveillance among TB suspects at some sentinel sites
• RCT among HIV-infected TB patients comparing daily v/s
intermittent regimens
Role of Medical College in TB/HIV
collaborative activities
• Academics
– Frequent updates / CMEs for faculty and students
– Demonstration of TB/HIV care settings to students
• Patient Care
– Implementation of ICF and IC at ICTCs and ART centres
– Implementation of PITC for TB patients and Early ART
initiation for HIV-infected TB patients
• Research
– Operational Research and PG Thesis
– Funding available under RNTCP
• Quality Assurance
– Part of RNTCP Internal Evaluations and Joint TB/HIV Visits
– Peer Pressure on professional colleagues to follow ISTC
Thanks..
A dedicated webpage for TB-HIV
Fly UP