Sanghyuk Shin, PhD Department of Epidemiology UCLA Fielding School of Public Health Aug 27, 2015 Tuberculosis and HIV Co-infection: “A Deadly Syndemic”

Photograph: Union Rescue Mission ( LA County Homeless Estimated 60,000 in LA County 5000 in downtown Skid Row TB outbreak 92 cases since deaths (17%) 21% HIV infected TB Outbreak among Homeless Persons in LA County

1. Background on Tuberculosis 2. Impact of HIV on TB epidemic 3. TB and HIV among LA County homeless persons Outline

Tuberculosis Background

CDC Division of Tuberculosis Elimination website at Active Tuberculosis Disease Symptoms

TB infection and disease

Active TB disease due to new infection

TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection

TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection Active TB disease due to reactivation of old infection

TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection Active TB disease due to reactivation of old infection 90% never develop disease

Detection of TB infection Tuberculin skin test (TST or PPD) 2-3 days

Detection of TB infection Tuberculin skin test (TST or PPD) Blood tests -T.Spot -QuantiFERON 2-3 days

Detection of TB disease Symptoms Sputum microscopy Chest X-ray Culture Molecular tests

Tuberculosis Treatment At least 6 months of drug therapy  Coughing and symptoms stop after 2 months Treatment = prevention  Prompt diagnosis  Completion of appropriate treatment

Trends in incidence of active TB WHO, Global Tuberculosis Report 2014

Multi-drug resistant TB (MDR-TB) Extensively drug resistant TB (XDR TB) Drug-resistant TB Major global health threat

TB/HIV co-infection

“A syndemic is a set of intertwined and mutually enhancing epidemics involving disease interactions at the biological level…” Singer 2003 Medical Anthropology Quarterly TBHIV

Drivers of TB Epidemic

Drivers of TB Epidemic HIV!!!

TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection Active TB disease due to reactivation of old infection Never develop disease

TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection Active TB disease due to reactivation of old infection Never develop disease HIV!!!

TB/HIV co-infection TB leading cause of death in PLHIV PLHIV infected with TB times more likely to develop active TB. 80% of all TB/HIV cases are in Africa

WHO, Global Tuberculosis Report 2014 HIV Prevalence among TB Cases, 2013

Kwan 2011 Clinical Microbiology Reviews “Excess” TB due to HIV in the US

Tuberculosis Treatment outcomes WHO, Global Tuberculosis Report 2014

TB and HIV among LA County Homeless Persons

Photograph: Union Rescue Mission ( LA County Homeless Estimated 60,000 in LA County 5000 in downtown Skid Row TB outbreak 92 cases since deaths (17%) 21% HIV infected Outbreak among Homeless Persons in LA County

Drivers of TB Epidemic HIV!!!

TB among Homeless Persons in the U.S. Bamrah 2013 International Journal of Tuberculosis and Lung Disease TB Rates 10-fold higher More likely due to recent infection Delayed detection and treatment Poor completion of treatment High mortality Substance use HIV co-infection 2-3x higher

“TB is the classic disease of poverty, and a classic case study of the impact of social conditions on disease.” Rasanathan et al. The social determinants of health: key to global tuberculosis control. INT J TUBERC LUNG DIS 15(6):S30–S36; 2011.

Historical trends

TB Prevalence Lowest vs. Highest Socioeconomic Status Lönnroth K. Risk factors and social determinants of TB. North American Regional Conference of the Union. Feb 24, Vancouver, BC, Canada.

New TB cases by Race/Ethnicity in the U.S. Scott et al MMWR

TB Rates by Income among Foreign-born Persons in the U.S. Olson 2012 BMC Public Health

What Can Be Done to Reduce TB Burden in Low-Income Communities?

Healthcare-related  Community health workers/peer health counselors  Mobile health clinics  Increase clinic hours  Travel vouchers  Free universal health insurance Social interventions  Housing  Financial support  Social welfare programs  Improved working conditions Hargreaves JR, Boccia D, Evans CA, Adato M, Petticrew M, Porter JD. The social determinants of tuberculosis: from evidence to action. Am J Public Health Apr;101(4): Interventions to overcome socio- economic barriers for TB/HIV

TB/HIV Co-infection Conclusions TB/HIV co-infection is a major public health concern HIV is the strongest known risk factor for TB disease HIV has had enormous impact on TB epidemiology Poor and marginalized communities most affected Interventions must address social conditions

Thank You! Photos from 1) Airborne: a journey into the challenges and solutions to stopping MDR-TB and XDR-TB / by John Donnelly. World Health Organization 2009, and 2) WHO Commission on Social Determinants of Health. Closing the Gap in a Generation. 2008