Preventing recurrent TB in high HIV-prevalent areas

Slides:



Advertisements
Similar presentations
TB/HIV Research Priorities in Resource- Limited Settings Where we are now and some suggestions for where to go Paul Nunn February 2005.
Advertisements

Discussion group 1 TB preventive therapy for PLWHA Alasdair Reid for Fabio Scano THD unit Stop TB department WHO.
Group III: Demand Forecasting
TB/HIV Research Priorities: TB Preventive Therapy.
HIV and Tuberculosis interaction and integration Anthony D Harries The “Union”, Paris, France London School of Hygiene & Tropical Medicine, UK.
M. Samarkos TUBERCULOSIS IN GREECE. INTRODUCTION.
Overview of current case and treatment outcome definitions Malgosia Grzemska TB Operations and Coordination Stop TB Department Consultation Impact of WHO-endorsed.
World Health Organization TB Case Definitions
PROGRAMMATIC OPERATIONAL RESEARCH DEVELOPMENT OF MALAWI’ S POLICY ON COTRIMOXAZOLE PREVENTIVE THERAPY R. Zachariah / AD Harries Contacts:
Module 3: Drug-Resistant TB. Learning Objectives Describe how drug resistance emerges Explain the difference between primary and secondary resistance.
KEY CHANGES IN THE NEW NTBLCP GUIDELINES
Monitoring and Evaluation Frameworks   What is an M&E Framework?   Why do we use M&E Frameworks?   How do we develop M&E Frameworks? MEASURE Evaluation.
A cost-effectiveness evaluation of preventive interventions for HIV-TB in Sub-Saharan Africa (Tanzania): Relevance for neurological infections Lucie Jean-Gilles.
Increasing HIV treatment for TB patients – thinking out of the box Anthony D Harries, The Union Paris, France.
Multi-drug resistant tuberculosis: Progress and challenges in South Africa Dr S. Moyo HIV/AIDS, Sexually Transmitted Infections and TB research (HAST)Programme.
Challenges of service integration: the TB model Linda-Gail Bekker The Desmond Tutu HIV Centre, Faculty of Health Sciences, University of Cape Town, South.
Johns Hopkins Center for Tuberculosis Research
Action Plan Good Health Situation of Population in Capital of Myanmar Yangon Division By DR MYA THIDA AYE.
DOTS-PLUS IN TANZANIA: PREPARATION PHASE Global DOTS Expansion Working Group Meeting, Paris: 28 October 2004 NTLP - MOH Prepared by: Dr. S. M. Egwaga NTLP.
Revising the WHO TB Treatment Guidelines Process and new recommendations Malgosia Grzemska Matteo Zignol Stop TB Department World Health Organization DEWG.
Health Organization The Challenges Facing Tuberculosis Control Blantyre Hospital, Malawi: TB Division, 3 patients per bed.
Trials and evidence in relation to health policy: The case of tuberculosis in Nepal and India Ian Harper.
TB Management: A Medical Aid Perspective presented by Dr Noluthando Nematswerani.
Strategic Information and the Control of Tuberculosis Brian Williams and Chris Dye TB programme, Monitoring and Evaluation, WHO.
Principles and Structure of a Research Protocol Anthony Harries The Union, Paris, France.
From operational research to policy and practice The Union, Paris, France MSF, Brussels, Belgium.
Operational research to Policy and Practice: examples Anthony D Harries, The Union, Paris, France London School Hygiene & Tropical medicine.
Roundtable. Detection and treatment of TB Andrew Black.
IMPAACT 2001 STUDY Mhembere T.P. (B. Pharm (Hons), MPH)
STREAM Trials Andrew Nunn MRC Clinical Trials Unit at UCL
Amir Shroufi Medical Coordinator MSF South Africa
A Way out of Directly Observed Therapy (DOT): Community approaches to Self-Administered Treatment for Rifampicin Resistant Tuberculosis in Khayelitsha,
TB/ HIV CONTROL AND MANAGEMENT IN SOUTH AFRICA
3rd International HIV/Viral Hepatitis Co-Infection Meeting HIV/Viral Hepatitis: Improving Diagnosis, Antiviral Therapy and Access Sunday, 17 July.
Monitoring and Evaluation: A Review of Terms
TUBERCULOSIS IN JAPAN ANNUAL REPORT – 2016.
Monitoring and Evaluation Frameworks
TB- HIV Collaborative activities in Romania- may 2006 status
Charles D. Wells, MD Chief, International Research and Programs Branch
February 03, 2011 Daniel G. Datiko
Daffodil International University (DIU), Dhaka Bangladesh
Dr Dawood Quiz questions.
PAEDIATRIC TUBERCULOSIS MAY STILL BE UNDER DIAGNOSED AND UNDER TREATED
CommCare as a Tool to Reduce Loss to Follow Up
Progress in Implementation of TB/HIV Collaborative activities
11/23/2018 National University of Lesotho, Southern Africa
Richard Laing, Kelly McGoldrick
World Tuberculosis Day 2016
Agenda Change Need greater clarity on lessons learnt and policy implications Time too short for working groups Afternoon plenary session.
Dr. Joseph Bana-Koiri Dr. Gilbert Hiawalyer Papua New Guinea
Tuberculosis Global Epidemiology
FRANCIS GAUSI and THOMAS NYIRENDA MALAWI.
Indian Scenario HIV Situation TB Situation
DOTS EXPANSION AND BEYOND DOTS World Health Organization
Cotrimoxazole Prophylaxis in HIV positive individuals Group A
Kevin M De Cock MD CDC Kenya Nairobi, September 21, 2003
Goal Objectives Expected Outcomes
Anthony D Harries Ministry of Health, Malawi
Cheng shiming National TB Center in China May,3, 2004
Surveillance for TB in HIV Care and Treatment Settings (CTS)
EXERCISE 11: Computing and Analyzing Program Indicators
TB epidemiology in Bulgaria
The ProTEST Projects:Achievements so far
Issues on the current information system
Country presentation Dr.Vija Riekstina National TB registry
Routine Counselling and HIV testing (CT) for TB patients in Malawi: Rhehab Chimzizi TB-HIV Programme officer National TB Control Programme-Malawi.
Fabio Scano IUATLD Conference Paris, 2003
33rd IUATLD World Conference on Lung Health
TB Screening and Differentiated Service Delivery: State of the Art
Strategic framework for TB/HIV
Presentation transcript:

Preventing recurrent TB in high HIV-prevalent areas What are the options for TB Control Programmes?

DEFINITION OF RECURRENT TB TB which re-occurs after a patient has been previously diagnosed with TB and completed a full course of treatment Bacteriologically confirmed or based on clinical criteria Due to reactivation or reinfection

EXTENT OF RECURENT TB: RESULTS OF STUDIES (1) Systematic review assessing the influence of HIV and rifampicin therapy 47 studies world wide 17 studies from sub-Saharan Africa (Korenromp, Scano, Williams, Dye, Nunn. Clin Inf Dis)

EXTENT OF RECURENT TB: RESULTS OF STUDIES (2) Recurrent TB (rate/pa) HIV-negative 1.9% HIV-positive 4.5% 7 months or > Rifampicin 1.4% 5-6 months Rifampicin 2.0% 2-3 months Rifampicin 4.0% [level of background TB is important]

EXTENT OF RECURRENT TB: REPORTS FROM NTPs AND WHO Problems NTP annual notifications to WHO include “Relapse”, “Failure” and “Rx after DF” WHO does not include “Failure” or “Rx after DF” in Global TB Reports NTPs do not notify WHO about recurrent smear-negative TB or EPTB

Case History: Malawi High HIV-prevalence country In 2000, 77% of TB patients HIV+ve 1990 - 1999 2- 4% all cases were relapse sm+ve PTB Almost no cases of recurrent sm-ve PTB / EPTB Operational research 1999 12% sm-PTB /EPTB registered as “new” cases had been previously treated for TB

From 1999, Malawi improved its registration of patients in terms of new and previously treated cases, especially with smear-ve PTB and EPTB

Malawi Case Notifications Year Total TB New Recurrent 1998 22674 22069 605 (3%) 1999 24396 23728 668 (3%) 2000 24846 22789 2057 (8%) 2001 27672 25217 2455 (9%) 2002 26532 23724 2808 (11%) recurrent TB = relapse, failures, treatment after default plus recurrent sm-ve PTB and EPTB

Why the need to reduce recurrent TB? Recurrent TB cases:- consume resources have a more difficult regimen increase TB transmission in the community cause additional morbidity and mortality erode faith in NTP amongst patients, staff, and community

Options to reduce risk of recurrence Use RH in continuation phase (CP) Extend duration of CP in HIV+ patients Give post-treatment isoniazid to HIV+ve patients who complete anti-TB treatment Treat HIV+ve TB patients with HAART

For each option: Evidence of effectiveness Current practice Operational considerations [consider especially for sub-Saharan Africa]

RH in Continuation Phase (CP) evidence of effectiveness Systematic review by Korenromp, Scano et al (Clin Inf Dis) IUATLD Clinical Trial A, RH throughout has lower recurrence than EH in CP [done mainly in HIV-negative patients]

RH in the CP: current practice in Africa All programmes use RH in IP Many programmes use EH in CP (6mo)

Option: Replace EH with RH in CP for all patients The dangers: RH needs distribution to all Rx outlets RH must be given by DOT Possible irrational use of RH If H resistance high, then R as “monotherapy” Risk of creating MDR-TB May increase difficulties with use of HAART

Extend duration of CP: evidence of effectiveness In HIV+ve patients: 2RHZE/4RH, then 6RH recurrent TB = 1.9% 2RHZE/4RH, then placebo recurrent TB = 9.0% (Perriens et al, NEJM 1995)

Extend duration of CP: current practice in Africa Not used by any TB programme in Africa

Option: Extend duration of CP for HIV+ve patients Need knowledge of HIV-status and therefore need links with VCT Evidence only for RH (although may work for EH) Different lengths of Rx for HIV+ve and HIV-ve patients, and may cause confusion Long use of RH may delay start of HAART

Provide IPT to HIV+ve patients who complete treatment: evidence of effectiveness Study in Haiti HIV+ve patients: 2RHZ/4RH, then 12H recurrent TB = 1.4% 2RHZ/4RH, then placebo recurrent TB = 7.8% (Fitzgerald et al, Lancet 2000)

Post-treatment isoniazid: current practice in Africa Not used by any TB programme in Africa

Option: IPT to HIV+ve patients who complete Rx Need knowledge of HIV-status and therefore need links with VCT Adherence may be better than with 1o IPT What is the optimal length of 2o IPT ? Who administers and monitors 2o IPT ? Will HAART obviate the need for 2o IPT?

Treat HIV+ TB patients with HAART: evidence of effectiveness In West, HAART reduces risk of TB in HIV-positive persons In South Africa HAART reduces risk of TB in HIV-positive persons (2.4% vs 9.7% pa) [Risk reduction most in the immunocompromised] No studies showing effect for recurrent TB

HAART to HIV+ve TB patients: current practice in Africa Not used by any TB programme in Africa

Option: HAART to HIV+ve patients with TB Need knowledge of HIV-status and therefore need links with VCT Need significant increased funding Need a structure for safe and secure supply and delivery of HAART

WAYS FORWARD Country TB programmes to determine true burden of recurrent TB If burden is high, then determine which of the four options is most cost-effective, feasible and least dangerous to do - Clinical studies / operational research / philosophy of “learn as we do”