1. Haileyesus Getahun, MD, PhD, MPH. Stop TB Department, WHO Geneva, Switzerland Tuberculosis among people who inject drugs: urgent actions needed. IHRAs 22 nd International Conference, 3-7 April, Beirut, Lebanon.

2. Outline of presentation Magnitude of the problem and evidence WHO, UNAIDS and UNODC policy framework Key recommendations and operational issues Challenges Conclusion

3. 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 2 nd line Transmitted by Coughing Sneezing

4. Estimated number of cases Estimated number of deaths 1.3 million* (range, 1.2–1.5 million) 9.4 million (range, 8.9–9.9 million) 0.5 million All forms of TB (men and women) Multidrug-resistant TB (MDR-TB) HIV-associated TB 1.1 million (12%) (range, 1.0–1.2 million) 0.4 million (range, 0.32–0.45 million) The global burden of TB in 2009 *excluding deaths among HIV+ people ~ 0.15million All forms of TB (in women) 3.6 million (38%) (range, 3.4–3.8 million) 0.5 million (range, 0.4–0.6 million)

5. Incidence of TB per 100,000 population Prevalence of injecting drug use per 100,000 No report Reported, no estimate >1000 500-1000 250-500 0-250

6. 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 Estimated HIV prevalence in new TB cases (%) 0–4 5–19 20–49 50 and higher No estimate

7. Country (yr)Drug usedTST +TB disease Iran (2001) 1 Heroin, opium40%6.4% USA (2002) 2 Heroin, crack29%NR USA (2007) 3 Crack cocaine28%NR TB risk is high in PWUD regardless of HIV 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. Pre-HIV era studies: 10x more risk of TB in PWUD

8. 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%OR95%CI Adjusted OR95% CI MSM18.2 1 IDU40.83.102.6-3.82.582.1-3.2 Heterosexual26.51.631.3-2.11.961.5-2.6 Unknown17.70.970.6-1.61.010.6-1.7 TB disease risk is high among PWID

9. TB, IDU and incarceration linkage PLHIV who inject drugs and developed TB have a four fold increased risk of incarceration 1 Up to 74% prisoners injected and up to 94% shared equipment while in prison 2 78% PWID were incarcerated and 30% injected while in prison 3 References 1.J Epidemiol 2011 ;21 (2) :108-113 2.Lancet Infec Dis 2009;9:57-66 3.BMC Public Health 2009, 9:492 doi:10.1186/1471-2458-9-492

10. TB in prison 1 in 11 TB cases in high income countries 1 in 16 TB cases in mid- low income countries Prison transmission 23 times more risk of TB disease in prisoners than the general population PLoS Med 7(12): e1000381. doi:10.1371/journal.pmed.1000381

11. Table 4 Statistically significant differences in rates of drug resistance among all tuberculosis patients in the civilian and penitentiary sectors. Civilian sector (%) Penitentiary sector (%) RR (95% CI) Any resistance47.267.5 1.4 (1.3–1.6) MDR TB22.940.9 1.8 (1.5–2.2) MDR TB is common among prisoners Ref : Dubrovina et al INT J TUBERC LUNG DIS 2008; 12:756–762

12. Lower survival of TB patients who inject drugs

13. 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) HBV37/18719.8 (14.3-26.2) HCV22/18711.8 (7.5-17.3) HIV35/20517.1 (12.2-23.9) Source: Pando et al Journal of Medical Microbiology (2008), 57, 190-197 HBV and HCV common among TB patients

14. The policy guidance Recommendations Multisectoral coordination TB screening and prevention HIV testing and prevention Treatment of TB and co-morbidities Integrated service delivery

15. Functional multisectoral coordinating body Composition National AIDS and TB Programs Harm reduction programs Criminal justice system Social care and psychological services Representatives of people who use drugs Functions Favorable policy, programme and legislative environment Promote evidence base practice and programs Develop TB/HIV national strategic plan Define roles and responsibilities of stakeholders

16. TB screening and isoniazid preventive therapy (IPT) Setting Sen (%) Spe (%) Negative Predictive Value (95% CI) Community766197.3 (96.9-97.7) Clinical893098.3 (97.5-98.8 CD4 < 200942298.9 (95.8-99.5) CD4> 200833496.9 (95.1-98.0) Symptom based TB screening is sufficient to exclude TB among PLHIV who use drugs and provide at least 6 months IPT None of current cough, fever, night sweats or weight loss = No TB = IPT Getahun et al PLoS Medicine 2011

17. Table 2. Final results of treatment of latent TB in 415 long term drug users who received INH7 days OutcomeNo (%) Completed treatment correctly319 (76.9) Abandoned or changed treatment71 (17.1) Elevation in ALT/AST 3-5X normal34 (8.2) Hepatotoxicity all20 (4.8) Hepatotoxicity clinical6 (1.4) Removed for other reasons5 (1.2) Source: Fernandez-Villar et al Clinical Infectious Diseases 2003; 36:293–8 IPT is not toxic to people who use drugs Excessive alcohol consumption (OR 4.2, P=0.002) and underlying liver disease (OR=4.3, P=0.002) are associated with hepatoxicity

18. 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

19. 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.

20. 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

21. 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

22. Conclusion Consensus Statement of the Reference Group to the United Nations on HIV and Injecting Drug Use, 2010. Addressing TB among IDUs is a public health priority.

23. 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 co- morbidities among PWUD save lives. Services should be scaled-up in a client friendly manner with due respect to basic human rights

24. Acknowledgement A. Ball A. Baddeley L. Blanc R. Granich C. Gunneberg A. Reid D. Sculier C. Smyth A. Verster