IHRA s 22 nd International Conference 3 -7 April

IHRA’s 22 nd International Conference, 3 -7 April, Beirut, Lebanon. Tuberculosis among people who inject drugs: urgent actions needed. Haileyesus Getahun, MD, Ph. D, MPH. Stop TB Department, WHO Geneva, Switzerland

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 -40 X • Isoniazid prevents TB in PLHIV • Drug susceptible TB: curable with <20 USD/patient • Drug resistant TB § MDR: Resistance to INH & R § XDR: Resistance to 2 nd line Transmitted by Coughing Sneezing

The global burden of TB in 2009 Estimated number of cases All forms of TB (men and women) 9. 4 million (range, 8. 9– 9. 9 million) All forms of TB (in women) 3. 6 million (38%) (range, 3. 4– 3. 8 million) HIV-associated TB 1. 1 million (12%) (range, 1. 0– 1. 2 million) Multidrug-resistant TB (MDR-TB) 0. 5 million Estimated number of deaths 1. 3 million* (range, 1. 2– 1. 5 million) 0. 5 million (range, 0. 4– 0. 6 million) 0. 4 million (range, 0. 32– 0. 45 million) ~ *excluding deaths among HIV+ people 0. 15 million

Incidence of TB per 100, 000 population Prevalence of injecting drug use per 100, 000 No report Reported, no estimate >1000 500 -1000 250 -500 0 -250

Estimated HIV prevalence in new TB cases (%) 0– 4 5– 19 20– 49 50 and higher No estimate Prevalence of HIV among PWID (%) 0 -4 5 -9 10 -19 20 -39 40+ IDU report, no HIV in PWID, no estimate No reports

TB risk is high in PWUD regardless of HIV Pre-HIV era studies: 10 x more risk of TB in PWUD Country (yr) Iran (2001)1 USA (2002)2 USA (2007)3 Drug used TST + Heroin, opium 40% Heroin, crack 29% Crack cocaine 28% References 1. Askarian et al East Mediterr Health J 2001; 7: 461– 4. 2. Howard et al Clin Infect Dis. (2002) 35 (10): 1183 -1190 3. Grimes et al Int J Tuberc Lung Dis 2007; 11: 1183– 9. TB disease 6. 4% NR NR

TB disease risk is high among PWID 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 MSM IDU Heterosexual Unknown Adjusted 95%CI OR 95% CI % OR 18. 2 1 40. 8 3. 10 2. 6 -3. 8 26. 5 1. 63 1. 3 -2. 1 17. 7 0. 97 0. 6 -1. 6 2. 58 2. 1 -3. 2 1. 96 1. 5 -2. 6 1. 01 0. 6 -1. 7

TB, IDU and incarceration linkage • PLHIV who inject drugs and developed TB have a four fold increased risk of incarceration 1 • Up to 74% prisoners injected and up to 94% shared equipment while in prison 2 • 78% PWID were incarcerated and 30% injected while in prison 3 References 1. J Epidemiol 2011 ; 21 (2) : 108 -113 2. Lancet Infec Dis 2009; 9: 57 -66 3. BMC Public Health 2009, 9: 492 doi: 10. 1186/1471 -2458 -9 -492

TB in prison Prison transmission • 1 in 11 TB cases in high income countries • 1 in 16 TB cases in midlow income countries PLo. S Med 7(12): e 1000381. doi: 10. 1371/journal. pmed. 1000381 23 times more risk of TB disease in prisoners than the general population

MDR TB is common among prisoners Table 4 Statistically significant differences in rates of drug resistance among all tuberculosis patients in the civilian and penitentiary sectors. Civilian sector RR (%) Penitentiary sector (%) Any resistance 47. 2 67. 5 (95% CI) 1. 4 (1. 3– 1. 6) MDR TB 22. 9 40. 9 1. 8 (1. 5– 2. 2) Ref : Dubrovina et al INT J TUBERC LUNG DIS 2008; 12: 756– 762

Lower survival of TB patients who inject drugs

HBV and HCV common among TB patients 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

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) None of current cough, fever, night sweats or weight loss = No TB = IPT Setting Sen Spe Negative Predictive (%) Value (95% CI) Community 76 61 97. 3 (96. 9 -97. 7) Clinical 89 30 98. 3 (97. 5 -98. 8 CD 4 < 200 94 22 98. 9 (95. 8 -99. 5) CD 4> 200 83 34 96. 9 (95. 1 -98. 0) Getahun et al PLo. S Medicine 2011 Symptom based TB screening is sufficient to exclude TB among PLHIV who use drugs and provide at least 6 months IPT

IPT is not toxic to people who use drugs Table 2. Final results of treatment of latent TB in 415 long term drug users who received INH≥ 7 days Outcome Completed treatment correctly Abandoned or changed treatment Elevation in ALT/AST 3 -5 X normal Hepatotoxicity all Hepatotoxicity clinical Removed for other reasons No (%) 319 (76. 9) 71 (17. 1) 34 (8. 2) 20 (4. 8) 6 (1. 4) 5 (1. 2) Source: Fernandez-Villar et al Clinical Infectious Diseases 2003; 36: 293– 8 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 CD 4 <10 and were started ART All of them completed TB treatment and CD 4 >200 • Key factor for success: on site access for TB dx The example of All Ukrainian Network of PLHIV Konstantin 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 “Addressing TB among IDUs is a public health priority. ” Consensus Statement of the Reference Group to the United Nations on HIV and Injecting Drug Use, 2010.

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 comorbidities 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