INFORMACI

1
REFLECTIONS ON HIV/AIDS AND MDR
PAHO/WHO
Dr. Andrea Luna Heine Resident/Consultant,
USAID/PAHO Training Program SupraNational
Reference Laboratory, Chile
2
1. Current Situation 2. Evidence Found
Conclusive? 3. Getting Closer to an Answer
3
1. Current Situation
4
Estimated Total Population Living with HIV/AIDS
(end of 2001)
Eastern Europe and Central Asia 1 million
Western Europe 560,000
North America 940,000
East Asia and Pacific 1 million
North Africa and Mideast 440,000
Central America 420,000
South East Asia 6.1 million
Sub-Saharan Africa 28.1 million
South America 1.4 million
Australia 15,000
Total 40 million
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The highest estimated rates for TB are found in
Africa
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Growing Tendency of TB Incidence
(African and Eastern European Countries)
200
180
Africa, low HIV
160
Africa, high HIV
Post-communist countries
140
120
Notification Rates per 100,000
100
80
60
40
20
0
1980
1985
1990
1995
2000
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Estimated Distribution of Adults Infected with
HIV and Tuberculosis, 2000
100,000
50,000
50,000
400,000
150,000
South East Asia 2.3 million
Sub-Saharan Africa 9.5 million
450,000
5,000
Global Total 13 million
8
In Africa, more HIV means more TB however, the
MDR rate is relatively low.
Zimbabwe MDR1.9
Malawi MDR0.3
Kenya MDR0.5
Tanzania MDR0.9
Ivory Coast MDR5.3
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Impact of HIV on Tuberculosis(USA, 19801992)
Cases (thousands)
35
30
observed
25
57,000 more cases
20
15
foreseen
10
5
0
79
80
81
82
83
84
85
86
87
87
88
89
90
91
92
93
Year
10
Estimated Percentage of MDR among New TB Cases,
2000
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Prevalence of HIV Infectionamong TB Patients
(Selected Countries, Region of the Americas,
2001)
NY 199726
English Caribbean (2000) BAH 38 BEL 14
GUY 32.4 JAM 16 SUR 14 TRT 32
DOR 1997 17
HON 20018.0
MEX 1990-1994 3.1
GUT20008.0
ELS 19962.8
NIC1999 0.8
Rio de Janeiro BRA1995-199835.6
Sources Reports from National
TB-Control Programs. Caribbean Epidemiology
Centre (CAREC).
ARG 1995 2.2
URU19970.7
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Prevalence of MDRamong Cases Never Treated
(Region of the
Americas, 19942002)
CAN 1.2
-
USA 1.2
DOR 6.6
CUB 0.3
Puerto Rico 2.5
MEX 3 states 2.4
GUT 0.7
VEN 0.3
HON 1.8
ELS 0.3
NIC 1.2
COL 1.47
ECU 6.6
BRA 0.9
PER
BOL
3.0
1.2
No data
CHI
-
gt 3
ARG
0.6
-
lt 3
0.9
URU
-
lt 1
0.01
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2. Evidence Found Contradictory?
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Is there any association between HIV and TB/MDR ?
of resistance to one or more drugs
Gordin 1996
Bercion 1995
Ash 1996
Dosso 1999
Spellman 1997
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Are hospitals a risk factor for HIV ?
10
Odds Ratio (95CL)
1
0.1
Espinal 2001
Yoshiyama
Kenyon 1999
Kenyon 1999
2001
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How reliable are the publications on this?
Certain methodological errors crop up frequently.
Non-representative samples

• Samples not randomized.
• Methodological defects in sample design
  (descriptive estimates, small size)
• Subproducts
• (Designed with other objectives in
  mind.)

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How reliable are the publications on this?
Certain methodological errors crop up frequently.
Biases

• Information Bias
• Fails to report previous treatment.
• Fails to report contacts (MDR).
• Memory Bias
• Fails to remember medication given
  (incorrectly reported as 'never treated').
• Selection Bias
• Serious or uncompensated percentages.
• Hospital reports.
• Informed consent.

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How reliable are the publications on this?
Certain methodological errors crop up frequently.
Factors Creating Confusion

• No DOTS
• Flexibility in observed treatment.
• Irregularity in treatment.

• Exposure to MDR Strains
• Less time in hospitals with a greater probability
  of MDR contact.

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How reliable are the publications on this?
Certain methodological errors crop up frequently.

• Non-TB micobacteria
• Late diagnosis

Diagnosis
Existence of outbreaks?

• Differentiated behavior
• Outbreaks?
• Can become generalized among the general
  population (Cluster RFLP)

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HIV/AIDS High Prevalence of MDR
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Lack of Control in the DOTS Strategy HIV/AIDS
High Prevalence of MDR
22
(No Transcript)
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MDR in New York(19922000)
Source New York City Department of Health.
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3. Coming closer to an answer ...
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Initial Resistance Study (Chile, 2001)

•  
• Samples input 939 (737)
• Samples useful for evaluation 867
• Discarded samples 70 (7.5)
• 3.2 due to false report of 'never treated'
  (30)
•  1.4 due to non-TB micobacteria (13)
•  2.9 for technical reasons (19 with no data y
  8 contaminated)
•  

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Verifying the Information

•  Initial survey.

•  Cross-referencing national TB databases.

• ENO (EX-RMC14) Epidemiology
• Registered monthly lab cases ISP
• Dynamic monthly RNTBC Nursing

• Review of 100 of the files with gt 1
  resistance.
• Review of a variable percentage of files from
  sensitive patients x health service from 20
  to 100.

•  Cross-referencing CONASIDA data on HIV/AIDS.

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Trends of Initial and Acquired Resistance
Global-Resistance and Multi-Resistance Forms
(19712001)
GlobalInitialResistance
AcquiredInitialResistance
InitialMulti-Resistance
AcquiredMulti-Resistance
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General Characteristics
Analysis of the Impact of HIV/AIDS and the
Immigrant Population

• There is no difference in the characterization of
  the population as regards sex and age among the
  resistant and non-resistant population.
• The population profile is not affected by
  populations with HIV/AIDS and migrants but this
  is the case if there is change within these
  populations vis-à-vis the national population.

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General Characteristics
Analysis of the Impact of HIV/AIDS and the
Immigrant Population

• The population co-infected with HIV/AIDS in this
  sample was 3.4.
• Neither of the two subpopulations affects the
  national resistance profile.

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Sample Characterization

• Regarding HIV/AIDS
• Patients with HIV/AIDS 3.3 of all
  'never-treated' TB cases.
• Average age, 37.2 MD 37, 80 of the
  population is male.
• 1.1 of the patients are MDR (0.7 national MDR).
• Regarding being an immigrant
• Foreign patients 2.3 of TB cases 'never
  treated'.
• Average age, 33.5 MD 29.5 60 are women.
• 1.1 of the patients are MDR.

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• What Other Chilean Studies Show
•  
• HIV patients act as an outbreak.
• 2.4 are MDR among 'never treated'
  (naive) TB-HIV/AIDS patients (national
  estimate 0.7)
• 19.8 are MDR among previously treated
  TB-HIV/AIDS patients (national estimate 20)

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HIV/AIDS
TB
MDR
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HIV/AIDS
TB Micobacteria?
Misreported as never treated?
MDR
TB
DOTS?
Outbreak?
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Summing UpHIV/AIDS and MDR TB

• The global evidence available (Africa, USA,
  etc.), as well as Regional experiences (Chile),
  do not indicate any causal association.
• HIV, however, can be a factor interacting in the
  generation of MDR TB, above all in the presence
  of poor tuberculosis control and insufficient
  biosafety measures.
• The lack of compliance with strictly supervised
  anti-TB treatment, as well as exposure to other
  MDR TB patients, constitute risk factors for drug
  resistance among this population group.