Transcript Tuberculosis among people who inject drugs

IHRA’s 22nd International Conference, 3-7 April, Beirut, Lebanon.
Tuberculosis among people who inject
drugs: urgent actions needed.
Haileyesus Getahun, MD, PhD, MPH.
Stop TB Department, WHO
Geneva, Switzerland
Outline of presentation
• Magnitude of the problem and evidence
• WHO, UNAIDS and UNODC policy framework
• Key recommendations and operational issues
• Challenges
• Conclusion
What is TB?
• One in three are infected with
M. tuberculosis
• Risk of TB in PLHIV: 20-40X
• Isoniazid prevents TB in PLHIV
• Drug susceptible TB: curable
with <20 USD/patient
• Drug resistant TB
 MDR: Resistance to INH & R
 XDR: Resistance to 2nd line
Transmitted by
Coughing
Sneezing
The global burden of TB in 2009
Estimated
number of
cases
All forms of TB
(men and women)
9.4 million
(range, 8.9–9.9 million)
All forms of TB
(in women)
3.6 million (38%)
(range, 3.4–3.8 million)
HIV-associated TB
1.1 million (12%)
(range, 1.0–1.2 million)
Multidrug-resistant
TB (MDR-TB)
0.5 million
Estimated
number of
deaths
1.3 million*
(range, 1.2–1.5 million)
0.5 million
(range, 0.4–0.6 million)
0.4 million
(range, 0.32–0.45 million)
~
*excluding deaths among HIV+ people
0.15million
Incidence of TB per 100,000 population
0–24
25–49
50–99
100–299
300 and higher
No estimate available
Prevalence of injecting drug use per 100,000
No report
Reported, no estimate
>1000
500-1000
250-500
0-250
Estimated HIV prevalence in new TB cases (%)
0–4
5–19
20–49
50 and higher
No estimate
Prevalence of HIV among PWID (%)
0-4
5-9
10-19
20-39
40+
IDU report, no HIV
HIV in PWID, no estimate
No reports
TB risk is high in PWUD regardless of HIV
Pre-HIV era studies: 10x more risk of TB in PWUD
Country (yr)
Iran (2001)1
USA (2002)2
USA (2007)3
Drug used
Heroin, opium
Heroin, crack
Crack cocaine
TST +
40%
29%
28%
References
1. Askarian et al East Mediterr Health J 2001; 7:461–4.
2. Howard et al Clin Infect Dis. (2002) 35 (10): 1183-1190
3. Grimes et al Int J Tuberc Lung Dis 2007; 11:1183–9.
TB disease
6.4%
NR
NR
TB disease risk is high among PWID
Factors associated with tuberculosis as an AIDS-defining disease (Barcelona 1994-2005) Source: Martin V et al J Epidemiol 2011 ;21 (2) :108-113
Risk Group
MSM
IDU
Heterosexual
Unknown
%
18.2
40.8
26.5
17.7
OR
Adjusted
95%CI
OR
95% CI
1
3.10 2.6-3.8
1.63 1.3-2.1
0.97 0.6-1.6
2.58 2.1-3.2
1.96 1.5-2.6
1.01 0.6-1.7
TB, IDU and incarceration linkage
• PLHIV who inject drugs and developed TB have a
four fold increased risk of incarceration1
• Up to 74% prisoners injected and up to 94%
shared equipment while in prison2
• 78% PWID were incarcerated and 30% injected
while in prison3
References
1.
2.
3.
J Epidemiol 2011 ;21 (2) :108-113
Lancet Infec Dis 2009;9:57-66
BMC Public Health 2009, 9:492 doi:10.1186/1471-2458-9-492
TB in prison
Prison transmission
• 1 in 11 TB cases in high
income countries
• 1 in 16 TB cases in midlow income countries
PLoS Med 7(12): e1000381. doi:10.1371/journal.pmed.1000381
23 times more risk of TB disease in prisoners than the
general population
MDR TB is common among prisoners
Table 4 Statistically significant differences in rates of drug resistance among all tuberculosis patients in the civilian and penitentiary sectors.
Civilian sector
RR
(%)
Penitentiary
sector (%)
Any resistance
47.2
67.5
(95% CI)
1.4 (1.3–1.6)
MDR TB
22.9
40.9
1.8 (1.5–2.2)
Ref : Dubrovina et al INT J TUBERC LUNG DIS 2008; 12:756–762
Lower survival of TB patients who inject drugs
HBV and HCV common among TB patients
Table 1. Prevalence of HIV, HBV and HCV among 205 patients with TB in Buenos Aires, Argentina, 2001
Organism
No. positive/ no.
studied
% Prevalence
(95% CI)
HBV
37/187
19.8 (14.3-26.2)
HCV
22/187
11.8 (7.5-17.3)
HIV
35/205
17.1 (12.2-23.9)
Source: Pando et al Journal of Medical Microbiology (2008), 57, 190-197
The policy guidance
Recommendations
•
•
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Multisectoral coordination
TB screening and prevention
HIV testing and prevention
Treatment of TB and co-morbidities
Integrated service delivery
Functional multisectoral coordinating body
• Composition

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

National AIDS and TB Programs
Harm reduction programs
Criminal justice system
Social care and psychological services
Representatives of people who use drugs
• Functions
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Favorable policy, programme and legislative environment
Promote evidence base practice and programs
Develop TB/HIV national strategic plan
Define roles and responsibilities of stakeholders
TB screening and isoniazid preventive therapy (IPT)
None of current cough, fever, night sweats or weight loss = No TB = IPT
Setting
Sen Spe Negative Predictive
(%) (%) Value (95% CI)
Community
76
61
97.3 (96.9-97.7)
Clinical
89
30
98.3 (97.5-98.8
CD4 < 200
94
22
98.9 (95.8-99.5)
CD4> 200
83
34
96.9 (95.1-98.0)
Getahun et al PLoS Medicine 2011
Symptom based TB screening is sufficient to exclude TB among
PLHIV who use drugs and provide at least 6 months IPT
IPT is not toxic to people who use drugs
Table 2. Final results of treatment of latent TB in 415 long term drug users who received INH≥7 days
Outcome
Completed treatment correctly
Abandoned or changed treatment
Elevation in ALT/AST 3-5X normal
Hepatotoxicity all
Hepatotoxicity clinical
Removed for other reasons
No (%)
319 (76.9)
71 (17.1)
34 (8.2)
20 (4.8)
6 (1.4)
5 (1.2)
Source: Fernandez-Villar et al Clinical Infectious Diseases 2003; 36:293–8
Excessive alcohol consumption (OR 4.2, P=0.002) and underlying
liver disease (OR=4.3, P=0.002) are associated with hepatoxicity
ART reduce TB risk by 54-92% among PLHIV
Lawn et al Lancet Infect Dis 2010;10: 489–98
Co morbidities, including viral hepatitis infection (such as hepatitis B and C),
should not contraindicate HIV or TB treatment for people who use drugs
Integrated TB, HIV and HR services
• Integrated service delivery initiated in 2008 :
- TB/HIV/HR services
- TB/HR services
• In 2009-2010, 25 TB/HIV sites established
• In one Kiev site in the first 6 months



20 PLHIV on ST were diagnosed with TB
All of them CD4 <10 and were started ART
All of them completed TB treatment and CD4 >200
• Key factor for success: on site access for TB dx
The example of All Ukrainian Network of PLHIV
Konstantin Lezhentsev, TB/HIV CG meeting presentation, Almaty, May 2010.
Key challenges
• Absence of data and lack of ownership
 Who should collect and communicate data?
 Who should own the services?
• Structural barriers
 Lack of collaboration among stakeholders
 Mandatory hospitalisation of TB patients in CAR and EE
• Additive toxicities and perception of HCW
• Stigma linked with multiple co-morbidities
• Lack of awareness by activists and advocates
TB/HIV Advocacy guide for HR advocates
• HIT and INPUD with
support by WHO, UNAIDS
and IHRA
• Based on existing TB/HIV
experiences
• Consultation on Sunday 3
April 2011 in Beirut.
• Document will be available
in July 2011.
Stronger civil society voice to promote human rights
based approach and accountability to the TB response
Conclusion
“Addressing
TB among
IDUs is a
public health
priority.”
Consensus Statement of the Reference Group to the United
Nations on HIV and Injecting Drug Use, 2010.
Conclusion
• Reliable global data on TB in people who use
drugs and among prisoners urgently needed.
• More TB ownership from prison and harm
reduction services and vice versa needed.
• Prompt co-treatment of TB, HIV and other comorbidities among PWUD save lives.
• Services should be scaled-up in a client friendly
manner with due respect to basic human rights
Acknowledgement
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A. Ball
A. Baddeley
L. Blanc
R. Granich
C. Gunneberg
A. Reid
D. Sculier
C. Smyth
A. Verster