Implementing IPT in the Context of TB/HIV in Thailand Saiyud Moolphate, B.N., M.P.H. TB/HIV Research Foundation, Thailand and The Research Institute of Tuberculosis, Tuberculosis Japan Anti-Tuberculosis Association (RIT/JATA)
The Symposium: Leadership to Address Challenges in TB/HIV Activism, Universal Access and Research The 41th Union World Conference on Lung Health November 10, 2010. Alsterhof Hotel. Berlin, Germany 1
Research funding (1993 - ) •
Japan Foundation for AIDS Prevention (JFAP)
•
The International Cooperative p Research Program g of the Ministry y of health and Welfare Japan (through RIT/JATA)
•
Double barred cross seal donation of Japan Anti-Tuberculosis Association (JATA)
R Researchers, h h health lth providers id and d policy li makers k Wat Uthaivoravit,, Pasakorn Akarasewi,, Pacharee Kantipong, p g, Surachai Piyaworawong, Supalert Nedsuwan, Pathom Sawanpanyalert, Jintana Ngamvithayapong, Sumalee Ammarinsangpen, Sittijate Komsakorn Toru Mori, Nobukatsu Ishikawa, Norio Yamada, Hideki Yanai 2
Population ~ 63.8 million Living with HIV ~ 610,000 1.4% HIV adult prevalence
TB cases ~ 55,000 55 000 TB incidence ~ 142/100,000 ranked 18th of the 22 high burden countries
Map of Thailand and Chiang Rai 3
Population 1.3 million Living with HIV 9922 2500 2000 1500 1000 500 0
HIV positive
HIV negative
HIV unknown 4
It was not TB program or AIDS program program.
Too many people died of HIV/AIDS in Chiang Rai.
There was nothing to offer to PLWH at that time. time IPT was the only thing appeared beneficial . 20 18 16 14 12 10 8 6 4 2 0
18.7 13.8
12.7 9
12.7
Sentinel sero-surveillance of military conscripts , Chiang Rai 10.7 9 6.5
6 6.7
5.6 4.4
33 3.2 2.8 3.3
1.6 2.1 1.8
0.8 1.2 0.5 0.2 0.6
6
Before IPT started knowing g HIV testing g result Æ went back home without interventions With Implementing IPT Once HIV –positive O iti status t t is i known k Æ TB screening (skin test, chest x-ray, sputum exam) TB education, and providing IPT with monthly follow up which means providing monthly counseling and care 7
Hospital
Intensified TB case finding
IPT
No.1
TB&HIV
TB
No.2
TB&HIV
TB
No.3
TB&HIV
TB
No 4 No.4
HIV&HIV
TB
No.5
TB&HIV
HIV
No.6
TB&HIV
HIV
No.7
HIV
TB
No.8
HIV
TB
No 9 No.9
TB
TB
No.10
HIV
HIV
No.11
HIV
HIV
No.12
HIV
HIV
No.13
HIV
HIV8
Country scale up IPT or the Northernism of IPT in Thailand? Does IPT stand for Ignoring of Preventive Therapy for TB?
Issue of efficacy, protective duration, TB re-infection, problem of adherence to IPT INH resistance
9
Year of research Area of research on Results Implication for policy Research and publication on IPT in Chiang Rai, Thailand implementation/ year IPT and study and or practice of publication
November 1993-August 1994
population
Adherence to 9-month IPT among 463 PLHIV In a regional hospital
Adherence rate = 67.5%. Recommendations for Reasons of non-adherence improving adherence to were identified IPT
Risk of default to IPT among 412 PLHIV in a community hospital
Default rates decreased from 57% in 1995 to 17% in 1999 Due to the contribution of PLHIV-volunteers PLHIV volunteers The preliminary analysis will be presented in the y p symposium.
(AIDS 1997: 11:107-112) 1995-1999 (AIDS. 2001 Sep 7;15(13):1739-41) 2004-2009
Impact of IPT, ART and IPT plus ART on TB incidence
PLHIV volunteers can contribute to ensuring adherence to IPT
IPT reduce risk of TB amongg PLHIV 10
Medicine Reminder Systems (developed by adherent clients)
26.49%
Major Reasons -migration for work, -denial and inability to cope p with HIV - side effects of INH.
Ngamvithayapong J, Uthaivoravit W, Yanai H, Akarasewi P, Sawanpanyalert P. Adherence to tuberculosis preventive therapy among HIV-infected persons in Chiang Rai, Thailand. Aids. 1997 Jan;11(1):107-12.
PLHIV network Not in PLHIV network
n
In-complete rate
Relative risk (95%CI)
284 128
76 (26.8) 60 (46.9) (46 9)
Reference 1 75 (1.35-2.27) 1.75 (1 35-2 27)
(Piyaworawong S, Yanai H, Nedsuwan S, Akarasewi P, Moolphate S, Sawanpanyalert P. AIDS 2001;15:1739-1741)
People with HIV volunteers play important role in ensuring adherence to IPT.
TB screening and IPT registration by PLHIV volunteer l t
TB and IPT education by PLHIV volunteer l t
Body weight, blood pressure, collect ll sputum by b PLHIV volunteer
100% 90% 80% 70%
% coomplete raate
60% 50% 40% 30% 20% 10% 0%
151, 393, 349, 648, 462,315, 228,111, 87, 60, 70, 163, 113, 83 ,188, 152, 122
4.7%
0.7% 2.3%
1.2% 1.2% 0.4% Complete loss follow up Death Side effect Stop by hospital
89.4%
Transfer out Unknown
N= 810
IPT ART
0.04
0.08
NO
0..06
0.10
Nelson-Aalen cumulative hazard estimates
0.00
0.02
IPT+ART
0
Phase
.5
Period
1 analysis time
2
phase =No.TB 0 phase Total episodes % = 1 Person-years Rate per 100py phase = 2
0 No history of IPT and ART
1.5
phase = 3
1,185
56 4.7%
923.3
1 After starting IPT
258
9 3.5%
332.0
2 After starting ART
603
37 6.1%
999.5
3 After starting ART and IPT
150
4 2.7%
270.7
5.8 2.7 3 3.7 1.5
1.5 1.4 1.3 1.2 11 1.1 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 02 0.2 0.1 0 NO
Baseline
IPT
Phase1
ART
Phase2
IPT+ART
Phase3
16
Among 3726 cases PLHIV in IPT program, 37 cases (1%) developed active TB during INH for 9 months. months TB treatment outcome of 37 cases 1
1
1
Success Default 21
8
Death Change diagnosi On treatment
3
Failure
Previously Treated Cases
20.0%
9.2%
18.0% 16.0% 14.0%
9.5%
12 12.0% 0% 10.0%
7.6%
8.0% 6.0%
3.1%
New Cases
4.0% 2.0% 0.0% 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
35
34.5
30 25
20 4 20.4 20 15
9.5
10 5
1997
12.4
2.02
9.7
2002
5.7 1.65
2006
2.6
0.93
1.4
MDR-TB in new case
Resistance to at least RIF in new case
0 Resistance to at least INH in new case
MDR-TB in previously treated patient
Source: WHO. Anti-tuberculosis drugg resistance in the world : fourth gglobal report. p
2008. and Fourth Review of the National Tuberculosis Programme in Thailand. Department of Disease Control Ministry of Public Health, Thailand World Health Organization; 2007.
Can IPT research in Chiang Rai influence policy and practice?
Implementation of IPT in 9 hospital to covering every region of Thailand by NAP and NAP, NAP
From Ignoring to Implementing IPT From Dying of TB to Preventing TB As a staff working in HIV clinic, I think TB screening is a standard of care for people with HIV. Providing IPT can prevent TB so that our clients will have better quality of life. IPT is i a partt off HIV care. My M colleague ll from f TB clinic collaborate with us to screen TB. At the beginning of implementing IPT, I was not confident but now I feel confident confident. Our HIV clients do not get sick with TB. I really appreciate the HIV volunteers. They play important role to ensure that their friends get IPT. (said by an HIV clinic staff of Wiang Chai hospital)
21