Haileyesus Getahun, MD, PhD, MPH.Stop TB Department, WHO

Geneva, Switzerland

Tuberculosis among people who inject drugs: urgent actions needed.

IHRA’s 22nd International Conference, 3-7 April, Beirut, Lebanon.

Outline of presentation

• Magnitude of the problem and evidence

• WHO, UNAIDS and UNODC policy framework

• Key recommendations and operational issues

• Challenges

• Conclusion

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 2nd line

Transmitted by

Coughing

Sneezing

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)

Incidence of TB per 100,000 population

0–24

25–49

50–99

100–299

300 and higher

No estimate availablePrevalence of injecting drug use per 100,000

No reportReported, no estimate >1000500-1000 250-5000-250

Prevalence of HIV among PWID (%)

0-45-910-1920-3940+IDU report, no HIVHIV in PWID, no estimateNo reports

Estimated HIV prevalence in new TB cases (%)

0–45–19

20–4950 and higherNo estimate

Country (yr) Drug used TST + TB diseaseIran (2001)1 Heroin, opium 40% 6.4%USA (2002)2 Heroin, crack 29% NRUSA (2007)3 Crack cocaine 28% NR

TB risk is high in PWUD regardless of HIV

References1.Askarian et al East Mediterr Health J 2001; 7:461–4.2.Howard et al Clin Infect Dis. (2002) 35 (10): 1183-11903.Grimes et al Int J Tuberc Lung Dis 2007; 11:1183–9.

Pre-HIV era studies: 10x more risk of TB in PWUD

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 % OR 95%CIAdjusted

OR 95% CI MSM 18.2 1 IDU 40.8 3.10 2.6-3.8 2.58 2.1-3.2 Heterosexual 26.5 1.63 1.3-2.1 1.96 1.5-2.6 Unknown 17.7 0.97 0.6-1.6 1.01 0.6-1.7

TB disease risk is high among PWID

TB, IDU and incarceration linkage

• PLHIV who inject drugs and developed TB have a four fold increased risk of incarceration1

• Up to 74% prisoners injected and up to 94% shared equipment while in prison2

• 78% PWID were incarcerated and 30% injected while in prison3

References1. J Epidemiol 2011 ;21 (2) :108-1132. Lancet Infec Dis 2009;9:57-663. BMC Public Health 2009, 9:492 doi:10.1186/1471-2458-9-492

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

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 resistance 47.2 67.5 1.4 (1.3–1.6)

MDR TB 22.9 40.9 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

Lower survival of TB patients who inject drugs

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)

HBV 37/187 19.8 (14.3-26.2)

HCV 22/187 11.8 (7.5-17.3)

HIV 35/205 17.1 (12.2-23.9)Source: Pando et al Journal of Medical Microbiology (2008), 57, 190-197

HBV and HCV common among TB patients

The policy guidance

Recommendations

• Multisectoral coordination• TB screening and prevention• HIV testing and prevention• Treatment of TB and co-

morbidities • Integrated service delivery

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

TB screening and isoniazid preventive therapy (IPT)

SettingSen (%)

Spe (%)

Negative Predictive Value (95% CI)

Community 76 61 97.3 (96.9-97.7)

Clinical 89 30 98.3 (97.5-98.8

CD4 < 200 94 22 98.9 (95.8-99.5)

CD4> 200 83 34 96.9 (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

Table 2. Final results of treatment of latent TB in 415 long term drug users who received INH≥7 days

Outcome No (%) Completed treatment correctly 319 (76.9)Abandoned or changed treatment 71 (17.1)Elevation in ALT/AST 3-5X normal 34 (8.2)Hepatotoxicity all 20 (4.8)Hepatotoxicity clinical 6 (1.4)Removed for other reasons 5 (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

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

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 PLHIVKonstantin Lezhentsev, TB/HIV CG meeting presentation, Almaty, May 2010.

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

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

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.”

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

Acknowledgement

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