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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)

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ImplementingIPTinthe Implementing IPT in the Context of TB/HIV in Thailand