Reducing the burden of TB amongst PWH: Challenges, Successes, and Lessons Learned Isoniazid Prevenve 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 seng Impact of Widespread Use of TB Prevenve 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 Naonal 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 Proportion with noPPD Median: 35 w Time to IPT Time to IPT Proportion with noPPD 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 beXer 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 idenfy 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 .