Reducing the burden of TB amongst PWH: Challenges, Successes, and Lessons Learned
Isoniazid Preven ve Therapy: What can be learnt from the Rio de Janeiro experience?
Betina Durovni Rio de Janeiro City Health Department Federal University of Rio de Janeiro Brazil – Rio de Janeiro
Brazil 181 million pop
. Among 22th WHO’s high burden TB countries
RIO DE JANEIRO CITY:
. Population: 6 million
. 20% live in favelas
Sources: WHO/HTM/TB/2007.376 Brazil’s Ministery of Health Health Department of Rio de Janeiro City Rocinha favela
Copacabana
Ipanema Lagoa
Rocinha
São Conrado Rio de Janeiro : Population: 6 million 20% live in favelas Public Health Units
Study and se ng
Impact of Widespread Use of TB Preven ve Therapy for Pa ents with Access to An retroviral Therapy in Rio de Janeiro, Brazil: A Phased Implementa on Trial
> 15,000 HIV pa ents in 29 Public Health units managed by the Health Department of Rio de Janeiro City IPT Na onal Policy Physician adherence to HIV and TB Guidelines in Rio De Janeiro, Brazil Saraceni V, Durovni B, King BS, Eldred L , Chaisson RE IUATLD PS-71800-10, 10 November 2007
Guidelines Proportion
PCP prophylaxis 97
CD4 results 96
Viral Load results 93
TST applied 45
IPT (when indicated?) 11 What are we trying to do?
• Decrease TB among HIV-infected – Increase number of TSTs among HIV-infected – Increase number of HIV-infected starting IPT
Approach: 1. Training HCW - TB-HIV, PPD and counseling 2. CAB 3. Advocacy 4. IEC Lessons learned
From the interviews (qualitative inquiry) with HCW the main barriers indentified were
The lack of doctors' knowledge on the protocol of TB prevention
The complexity of HIV treatment and HIV patients’ style of life are a limitation to IPT.
Doctor are concerned about the adverse effects of INH on HIV patients. TB rates by ARV and INH treatment status Rio de Janeiro, Brazil, 2003-2005
Incidence Rate Incidence Adjusted Exposure Person- TB (per 100 PYs) Rate Ratio Hazard Ratio* category Years cases (95% CI) (95% CI) (95% CI) 4.01 Naïve 3,865 155 REF REF (3.40-4.68) 1.90 0.48 0.41 HAART only 11,627 221 (1.66-2.17) (0.39-0.59) (0.31-0.54)
Isoniazid 1.27 0.32 0.57 395 5 only (0.41-2.95) (0.10-0.76) (0.18-1.82) 0.80 0.20 0.24 Both 1,253 10 (0.38-1.47) (0.09-0.91) (0.11-0.53) 2.28 TOTAL 17,140 391 (2.06-2.52)
* Adjusted for age, sex, CD4, prior history of TB
Golub JE, Saraceni V, Cavalcante SC et al. AIDS 2007 Golub et al Time to TST
Time to TST
Proportionwith no PPD
Median: 35 w Time to IPT
Time to IPT
Proportionwith no PPD
Median: 14 w Lessons learned • Did the strategy make any difference? – yes • Is it enough? (how much is enough?)– probably not • What else can be done or improved? Communication Advocacy Training Process analysis – quality approach TB-HIV Indicators (package) • HIV testing among TB patients • TST/IPT • TB culture for HIV patients (MGIT) • DOT for HIV patients Media/Communications
TB is a serious health crisis in Brazil and the developing world, and we need be er strategies to stop TB now.
We are working to change the way that TB is diagnosed, treated and prevented in high- People (with HIV) are It is possible to prevent TB burden countries around the dying unnecessarily among those living with HIV world. from TB
Our study is working at an unprecedented scale to iden fy the best ways to find, treat, and prevent TB on the frontlines of the pandemic.
Created by THRio’s Team & Ogilvy Analyzing the process Opportunities
Since 01 Sep 2005, 11.4% of all TB cases diagnosed among HIV patients were found in the process of ruling out TB before starting IPT Summary
• What does it really take to start IPT? • Where are the bottlenecks? • Which units are the most successful? How?
TB and HIV programs (planning, reports) Training Include patients, advocacy groups Team work –all levels Common Targets Quality approach – indicators Thank you! [email protected]
• Valeria Saraceni • Richard Chaisson • Giselle Israel • Jonathan Golub • Vitoria Velloso • Lois Eldred • Solange Cavalcante • Andrea De Luca • Lilian Lauria • Bonnie King