Transcript and what is it in TB?

DOT: Can we learn from
tuberculosis in the HIV
field?
Moïse Desvarieux, MD PhD
Chaire d’Excellence ANR,
Inserm UMR S 707
Associate Professor of
Epidemiology, Columbia University
Key differences in HIV vs TB
TB
• DOT is public health
mandate
– Physical to pharm
quarantine
– Therapy leads to noninfectiousness
– Casual transmission
• TB treatment 6-12 mo.
• Twice weekly
HIV
• No public health
mandate for treatment
– Sometimes for
transmission
– Not entirely clear, nor as
fast
– Sexual transmission
• Lifelong treatment
• Best is once daily
Biology and infection dynamics
are different
TB
• Long generation time
and slow emergence of
drug resistance
• MDR is iatrogenic
• No substantial effect of
food
HIV
• Short generation time
and error-prone reverse
transcriptase, rapid
emergence of
resistance
• Important effect of food
on bioavailability
• May DOT for ARV increase drug
pressure to a critical level where the
risk of drug resistance is subsequently
highest?
• But where does Directly Observed
Therapy for Tuberculosis stand?
Universal paradigm?
• One size-fits-all or custom-made?
• Home or clinic/hospital based?
• Family member or community worker?
Cochrane Review of DOT for Tuberculosis:
Impact on Cure
Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007
Cochrane Review of DOT for Tuberculosis:
Impact on Cure or treatment completion
Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007
Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007
Cochrane Review of DOT for Tuberculosis:
Impact of location of administration on cure
Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007
Cochrane Review of DOT for Tuberculosis:
Impact of location of administration on cure or treatment completion
Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007
Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007
Cochrane Review of DOT for Tuberculosis:
Impact of family member versus community health worker
Source: Volmink J, Garner P, et al Directly Observed Therapy for Treating Tuberculosis, 2007
Clearly, timing seems to matter in TB…
Source: Kruk ME, Schwalbe NR, Aguiar CA et al Timing of Default From Tuberculosis Treatment: A Systematic
Review 2008.
Clinical trials of DOT for HIV
should address
• Retention on therapy, virologic and
immunologic outcomes to at least one
year
• Development of drug resistance (in
spite of our a priori hypothesis)
• Cost-effectiveness (time and labor
intense)
• But what groups of patients?
– All
– New patients
– Low motivational state and Late-stage
disease (Bangsberg)
• Implications (and what is it in TB?)
• In Tuberculosis, the priority for
treatment is the most contagious form
• However, virologic tool for adherence
Social contextts
• The epidemics do cross but not
perfectly
• Impact of private sector
• As HIV moves to primary care, what
impact on supervision?
Source: Macq J, Torfoss T, Getahun H. et al Patient empowerment in Tuberculosis Control: Reflecting on Past Documented
Experiences. 2007
Source: Macq J, Torfoss T, Getahun H. et al Patient empowerment in Tuberculosis Control: Reflecting on Past Documented
Experiences. 2007
Conclusions
• Yes we can learn from TB experience
with DOT
• But do we really want to learn?
• What are our intrinsic beliefs
• Targeting is probably the key
• Impact of primary care and private
sector and the end of exceptionalism