Title: Casos de aids. Proporo segundo categoria de exposio e ano de diagnstico. Brasil 1983 1999
1Collaborative Course on Infectious
Diseases January 2008
LECTURE 3 TB/HIV Co-infection Epidemiology and
Control
Leda Fátima Jamal lejamal_at_crt.saude.sp.gov.br
Harvard School of Public Health (HSPH) Faculdade
de Ciências Médicas da Santa Casa de São Paulo
Brazil Studies Program, DRCLAS, Harvard
University
2Objectives
- Describe the epidemiology of co-infection TB/HIV
in Brazil - Understand the interaction between these two
diseases and the negative impact of one disease
on the other - Discuss how the implementation of health policies
in HIV/AIDS can impact the control of
tuberculosis in Brazil
3TB/HIV
4Tuberculose and HIV/Aids in Brazil
- TB
- 85,000 new reported cases/year
- 111,000 estimated cases/year
- 8 of TB carriers are also HIV
- AIDS
- 25,000 new cases/year
- 600,000 are HIV
- 15 of all AIDS cases are TB carriers
5Incidence of TB in Brazil, by State, 2005
6Percentage of patients with TB among reported
AIDS cases, Brazil, 1990-2006
Mean from 1990 to 2006 18.3
Source SINAN and PN-DST/AIDS (Data through
06/2006, predicted to 12/2006)
7- Cumulative incidence (1982-2004) of conditions
associated with AIDS
Source SINAN and PN-DST/AIDS (Data through
06/2006)
8Main factors of death associated with AIDS,
State of São Paulo, 1997 and 2001
Source Santo et al., Rev Saude Publica, 2002
9TB/HIV
10TB in HIV individuals
- HIV individuals are more likely to be infected
with TB. - HIV individuals are more likely to develop
active TB. - Progression rate from infection to active
disease 8 per year - Lifetime risk of TB 50
11TB in HIV individuals
- Rate of reactivation of TB in individuals
co-infected with HIV 8 per year - HIV infection Important risk factor for TB
- TB One of the most common complications among
HIV infected individuals - Advanced-stage AIDS (CD4 lt 150/mm3) TB
associated with 6.5 fold increase in risk of
death in the next 3 years
12TB in HIV individuals
- HIV-related Immunosuppression affects the
manifestation of tuberculosis in several ways - ? risk of active TB
- ? drug resistant TB
- ? mortality
- Although the risk of TB was decreased by HAART,
the risk of TB is still high - HAART improves survival in TB
- Interactions between TB and AIDS drugs make
medication management challenging
13Tuberculosis in individuals with HIV/AIDS, per
year. Referral and Training Center DST/AIDS,
1994-2005.
Considered only the first diagnosis or
recurrences cases related to non-compliance and
cases of non-infectious micobacterium are
excluded)
Source Epidemiologic Surveillance CRT-DST/AIDS
(Data until Aug/2005).
14TB/HIV
- Public Health strategies for TB control in PLWHA
15Burden of HIV on tuberculosis
- Excess of diagnosis of cases with negative sputum
smear - Low cure rates
- Increase in the rates of
- Noncompliance
- Death during treatment
- Recurrence
- Increased rates of resistant TB
16Test of sensitivity to anti-TB drugs in HIV
patients in their first or second diagnosis in
the service.Referral and Training Center
DST/Aids, 1994-2005.
Nº TS1596 TS288
N TS1526 TS278
Independently of sensibility test in the
first diagnosis Resistant to at least one of
the tested drugs Resistant to rifampin e
isoniazid
Source Epidemiological Surveillance
CRT-DST/Aids (Preliminary data until Aug/2005).
17- Detect 70 of estimated cases (goal met)
- Cure 85 of reported cases (2006 81)
- Decrease non-compliance to less than 5 (2006
7)
18Strategies to reduce TB-associated morbidity and
mortality in HIV individuals (1)
- Prevention of TB
- Early detection of TB
- Prompt initiation of treatment
- Ensuring compliance
19Strategies to reduce TB-associated morbidity and
mortality in HIV individuals (2)
- Prevention
- Use of highly active anti-retroviral therapy in
all patients unless contra-indicated. - Use of TB chemoprophylaxis in all patients
unless contra-indicated
20Treatment of latent TB in HIV and survival
de Pinho et al., AIDS 2001 Nov 9 15(16)2129-35.
21Strategies to reduce TB-associated morbidity and
mortality in HIV individuals (3)
- Early detection of TB
- Sputum smear, cultures and identification in all
patients suspected to have TB - Automated cultures to speed diagnosis/detection.
-
22Strategies to reduce TB-associated morbidity and
mortality in HIV individuals (4)
- Ensure compliance
- Supervised TB treatment to decrease
noncompliance, increase cure rates, and decrease
rates of drug resistance.
23Integration of TB and AIDS control strategies
(1)
- Objectives
- 2) Decrease the burden of HIV in patients with
TB - Prevention of HIV transmission
- HIV Counseling and testing
- ARV therapy
- Access to good quality medical services with
diagnostic capabilities -
24Integration of TB and AIDS control strategies (2)
- Objectives
- Decrease burden of TB in HIV patients
- ARV therapy
- TB case search (with implementation of
TB-confirming diagnostics) - Diagnosis of latent TB in HIV patients and
initiation of INH prophylaxis - Improvement of anti-TB and ARV treatment
compliance (decrease noncompliance and partial
compliance) -
25Conclusions
- What is needed
- Political commitment to the implementation of
TB/HIV control strategies - Better diagnostics
- Training of medical professionals on
co-infection Join planning of training courses
(TB/Aids/Laboratory) - Greater participation of the civil society in
TB/HIV control strategies (NGOs Aids)
26Questions for discussion TB/HIV
- How has AIDS changed the previously established
concepts/understanding of TB? - Is it possible to reach the goals of the TB
control program in light of the increase in
AIDS-associated TB cases? - What are the major obstacles in the
coverage/implementation of the TB
chemoprophylaxis in HIV individuals?
27For discussion Reasons for TB treatment
discontinuation, according to the year of the
initiation of treatment in the medical service.
CRT-DST/Aids,1994-2004.
of the total patients with known treatment
closure. 30 patients with other reasons for
treatment closure are included here (11 with
suspended treatment and 3 with treatment failure).
Source V.E.CRT - DST/Aids (Data until Aug/2005)
28For discussion
- Prevention of the development of TB in HIV
patients infected with TB - Initiate anti-retroviral therapy (as soon as it
is indicated) ARV therapy is the most important
strategy against the development of TB in HIV
patients infected with Mtb. - - National Program of STD/AIDS (PN-DST/Aids)
efforts in the early identification of
seropositivity are an important strategy in the
control of TB. - Identification, diagnosis, and treatment of TB
infection in HIV individuals Every HIV
individual must undergo TB diagnostic tests and,
when appropriate, receive anti-TB
chemoprophylaxis. - Obstacles
- Physicians may have difficulties to adopting
these strategies - Patients may have difficulties complying with
drug regimen (3 tablets a day).
29References
- Required
- Reid, A., Scano, F. et al. Towards universal
access to HIV prevention, treatment, care and
support the role of tuberculosis/HIV
collaboration. Lancet Infect Dis 2006 6483-95.
Available at http//infection.thelancet.com. - Jamal, LF Moherdaui, F. Tuberculosis and HIV
infection in Brazil magnitude of the problem and
strategies for control. Rev. Saúde Pública
2007 41 (suppl.1)104-10. Available at
http//www.scielo.br/pdf/rsp/v41s1/en_6545.pdf - Optional
- Golub, JE Saraceni, V. et al. The impact of
antiretroviral therapy and isoniazid preventive
therapy on tuberculosis incidence in HIV-infected
patients in Rio de Janeiro, Brazil. AIDS 2007,
211441-48. - Miranda, A., Morgan, M. et al. Impact of
Antiretroviral Therapy on the incidence of
Tuberculosis The Brazilian Experience,
1995-2001.PLoS ONE 2(9)e826.doi10.371/journal.po
ne.0000826