4th Annual Journalist-to-Journalist Lung Health Training

Discussion about TB and HIV
43rd Union World Conference on Lung Health Kuala Lumpur
Philippe Clevenbergh, MD Head of The Union Office in Myanmar International Union Against Tuberculosis and Lung Disease 14:30-15:45 Tuesday, November 13

Incidence of primary opportunistic infections in two human immunodeficiency virus-infected French clinical cohorts. Yazdanpanah Y, Chêne G, Losina E, Goldie SJ,
Merchadou LD, Alfandari S, Seage GR 3rd, Sullivan L, Marimoutou C, Paltiel AD, Salamon R, Mouton Y, Freedberg KA. Int J Epidemiol. 2001 Aug; 30 (4): 864-71.

Mycobacterium tuberculosis was the least common opportunistic infection (< 5.0/100 person-years).

Geographical differences exist in the incidence of HIV-related opportunistic infections.

Map of poverty (< 2 USD/day) 2010

TB – HIV interaction for the person
HIV increases the risk of progression to active TB in both primary TB infection and the reactivation of latent TB
– W/o HIV: 3 to 5% develop active TB in the first 2 years after TB infection – With HIV: 73% developed active TB within the first 6 months of TB infection

– W/o HIV: lifetime risk of developing active TB due to reactivation = 8 to 10%
– With HIV: risk = 10% per year

TB/HIV epidemiology in 2008
• 33.4 million PLWH: ~ 30% latent or active TB infection • 9.4 million TB cases: 1.4 million (15%) were coinfected with HIV • HIV infection is the strongest risk factor for TB. • PLWH: 20 to 30 times more likely to develop TB than those without HIV. • New TB cases 19 times more likely to be coinfected with HIV than general population

Top 10 OIs treated in 2011 in the IHC program in Myanmar among HIV-infected patients
Annual OI: 7015 patients treated Minor mucocutaneous manifestations Oral candidiasis Pulmonary tuberculosis Episodes 1,976 1,578 1,243 % 28% 22% 18%


Extrapulmonary tuberculosis
Herpes Zoster Recurrent upper respiratory tract infect Endemic mycosis Cryptococcosis Unexplained chronic diarrhoea

256 226 142 145 166

4% 3% 2% 2% 2%

Unexplained prolonged fever

Health solutions for the poor


Individual level
HIV - Increases the susceptibility to and accelerates progression of TB disease - Atypical presentation and delayed diagnosis of TB - Increase the risk of TB treatment failure and development of MDR and XDR TB - Increases risk of recurrence of TB - TB vaccine contra-indicated in children

Community level


TB - First cause of mortality among HIV infected individuals - Increases HIV replication and accelerates HIV disease - Makes treatment of HIV more complicated (timing and choice of drugs) - Is associated with specific complications after HIV treatment (IRIS)

HIV - Increase the number of TB cases and the spread of TB disease among HIV-infected patients and within the community - Increase the number of MDR and XDR TB cases - Share similar socio-economic features favoring transmission and affecting similar risk groups


TB - Increased mortality in HIVinfected people - Increased risk of transmission of HIV

Regional distribution of TB/HIV mirrors HIV, 2011

Americas (3%)

Estimated excess TB cases attributed to the worsening HIV epidemic in the United States from 1985 to 1992.

Kwan C K , Ernst J D Clin. Microbiol. Rev. 2011;24:351-376

TB is a leading cause of death among PLHIV
Studies Cote d’ Ivore1 USA2 Kenya3 Botswana4 South Africa5 India6 Uganda7 Year of study 1991 1996 1997 1998 2005 2007 2009 PLHIV found with TB (%) 44 33 51 40 79 63 37

References 1. Lucas et al , 1994 2. Afessa et al, 1998 3. Ranna et al, 2000 4. Ansari et al, 2002 5. Martinson et al, 2007 6. Lanjewar, 2011 7. Cox et al, 2012

430,000 PLHIV died of TB in 2011 (25% of AIDS deaths)

HIV-associated TB contributes disproportionately to TB-related deaths.

Kwan C K , Ernst J D Clin. Microbiol. Rev. 2011;24:351-376

WHO TB/HIV policy: 12 points policy package
• Establish the mechanism for integrated services (Joint NAP and NTP) • Decrease the burden of TB in PLHIV (Three Is and earlier ART) (Primarily NAP) • Decrease the burden of HIV in TB patients (Primarily NTP)

TB/HIV collaborative activities in Myanmar

HIV testing of TB patients in Africa
2007 2008 2009 2010 2011





2011 AMRO = 53% EURO = 52% SEARO = 32% WPRO = 25% EMRO = 11% Global = 40%

HIV testing among TB patients in Myanmar

HIV rapid test: point of care diagnosis

11,111th TB patient tested for HIV in Mandalay

Percentage of TB/VCCT testing among registered TB patients during July, August, September, 2012
100% 98% 98% 96% 94% 92% 92% 90% 88% 86% 84% 82% 80% 78% 85% 90% 97% 96% 95%








Percentage of TB/VCCT testing among registered TB patients

Health solutions for the poor

Positivity percent among HIV tested registered TB patients during July, August, September, 2012
25% 23%

20% 18% 19% 18%

15% 15% 14%

12% 10%










Positivity percent among HIV tested registered TB patients

Health solutions for the poor

- Advocacy - New drugs - New tools



New diagnostic tools
The World Health Organization estimates that one-third, or almost 3 million, of the world’s 8.8 million TB cases are never detected or reported let alone diagnosed, treated, and cured properly.
Ditiu L. Tackling tuberculosis with an all-inclusive approach. Interview by Sarah Cumberland. Bull World Health Organ. 2011 Mar 1;89(3):170–1. Available from: http://www.who.int/bulletin/volumes/89/3/11-040311.pdf. (Accessed 2012 June 28)

New diagnostic tools in the pipeline

TB diagnosis using smear microscopy

TB diagnosis using Chest X ray

Laboratory Strengthening in Mandalay
Use of available Tools for TB Diagnosis

Gene Xpert installed in TB OPD in Mandalay

Gene Xpert installed in TB OPD in Mandalay

Gene Xpert installed in TB OPD in Mandalay

Added diagnosis trough Gene Xpert
Smear microscopy result # SS+ Previously # SS New treated # SS- not done HIV test result Chest Xray result # UK abnormal

# GX Q3_2012 MTB+













New HIV drugs in the pipeline: 13
• Hopeful: Quad (elvitegravir/cobicistat/tenofovir/FTC), elvitegravir, cobicistat, GS-7340, dolutegravir, 572-Trii (dolutegravir/abacavir/3TC), and Quad variations (using GS-7340 and darunavir). • Early days: S/GSK1265744, lersivirine (UK-453061), BMS-986001 (formerly OBP-601), BMS-663068, cenicriviroc (TBR-652), rilpivirine-LA (long-acting injection).

• Trailing: apricitabine, ibalizumab (TMB-355; formerly TNX-355), CMX157, CTP-518.

New TB drugs in the pipeline: 6


The waiting room

PLWH network

Mobilization of PATB

The 3 ‘Is” => 4 “Is”
• Intensive case finding TB => HIV and HIV => TB • Infection control • Isoniazid preventive therapy • Earlier Initiation of antiretroviral drugs

TB Screening and IPT in TB/HIV burden countries, 2011
1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0

Countries represent the top 10 and 72% of global TB/HIV burden

TB Screening


TB patients tested for HIV (%)
Africa Global

Regions other than Africa

TB patients received ART (%)
Regions other than Africa Global Africa

TB/HIV patients Started on ART during July, August, September, 2012: 388 patients
180 168 160

140 117





40 20 20 23 14 18



0 Mandalay Pakokku Taunggyi Lashio Meikhtila Myingyan Monywa Tharkayta Number of TB patients who have started ART during the reporting period

Health solutions for the poor

ART services are still too centralized and too few

Number of facilities providing TB and ART, 2011

Integrated HIV Care Sites in Myanmar (Sites of ART programs supported by The Union)
Sagaing Monywa Yae Sakyo Myaing Pakokku Myingyan


Mandalay (7 townships)
Taunggyi Aye Thar Yar Kalaw

Saturated IHC site

Tharketa (Yangon)

New IHC site proposed to be opened in 2013/ Unsaturated IHC site

Health solutions for the poor

Service delivery points: - Mandalay - MGH ( 3 units + NAP) - MCH (300 + 550 bedded H) - MTH - CWH - UMTBC - 7 TSHC - Pakokku - PGH - Lashio - LGH - Taunggyi - SST - MCH - Monywa - MGH - Myekthila - MGH - Myinchan - MGH - Tarketha Total: 20 SDP

Health solutions for the poor

TB/HIV gaps in Myanmar
• Limited interactions between NAP and NTP • TB/HIV technical strategic group “pending” • Limited coverage for TB/HIV collaborative activities and implementation of the “4Is” • Limited access to ARVs • Limited access to MDR TB treatment • Unforeseeable risks of transmission of both diseases due to migrations accompanying economic boom

• TB and HIV epidemics are working hand in hand and mutually enhancing each other magnitude and impact at the individual and community level • TB/HIV co-epidemic can be addressed only as a single common global solution • Structural and socio-economic changes are required for both diseases • Both programs have to learn from each other in order to be successful

• Routine data collection from the Integrated HIV Care, The Union Office in Myanmar • HIV and Tuberculosis: a Deadly Human Syndemic. Candice K. Kwan and Joel D. Ernst. Clin. Microbiol. Rev. April 2011 vol. 24 no. 2 351-376 • Global response to TB/HIV: experiences and challenges. GFATM HIV and TB Disease Committees Meeting, Oct 22, 2012. Haileyesus Getahun. Stop TB Department. World Health Organisation, Geneva. • TB/HIV Activist Toolkit, TAG, Treatment Action Group http://www.treatmentactiongroup.org/tb/resources/activist-toolkits (last accessed 5/11/12) • Pipeline Report. HIV-HCV-TB. TAG, Treatment Action Group http://www.pipelinereport.org/toc/tb-treatment (last accessed 5/11/12)

Thank you!


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