Casos de aids. Proporo segundo categoria de exposio e ano de diagnstico. Brasil 1983 1999

1
Collaborative 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
2
Objectives

• 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

3
TB/HIV

• Epidemiology

4
Tuberculose 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

5
Incidence of TB in Brazil, by State, 2005
6
Percentage 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)
8
Main factors of death associated with AIDS,
State of São Paulo, 1997 and 2001
Source Santo et al., Rev Saude Publica, 2002
9
TB/HIV

• Infection and disease

10
TB 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

11
TB 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

12
TB 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

13
Tuberculosis 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).
14
TB/HIV

• Public Health strategies for TB control in PLWHA

15
Burden 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

16
Test 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)

18
Strategies to reduce TB-associated morbidity and
mortality in HIV individuals (1)

• Prevention of TB
• Early detection of TB
• Prompt initiation of treatment
• Ensuring compliance

19
Strategies 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

20
Treatment of latent TB in HIV and survival
de Pinho et al., AIDS 2001 Nov 9 15(16)2129-35.
21
Strategies 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.

22
Strategies 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.

23
Integration 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

24
Integration 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)

25
Conclusions

• 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)

26
Questions 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?

27
For 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)
28
For 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).

29
References

• 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