Surveillance for TB in HIV Care and Treatment Settings (CTS) Lisa J. Nelson, MD MPH MS TB/HIV Team Leader International Research and Programs Branch Division of TB Elimination, CDC

Timeline of TB/HIV Surveillance HIV infection TB diagnosed Timeline

Rationale for TB Surveillance in CTS TB is important cause of morbidity and mortality Care and treatment programs should have measurable effect TB may be well-suited to measure trends over time Possibility of studying other interventions

Antiretroviral Therapy (ART) Study Location # Enrolled TB Reduction Comment Brodt, AIDS 1997 Germany 1003 NS Only men w/ CD4<200 Lederberger, JAMA 1999 Switz. 2140 18% (-31, -3) Girardi, AIDS 2000 Italy 2160 HR 0.16 (0.03, 0.74) Jones, IJTLD 2000 U.S. 14,457 RR 0.2 (0.1, .05) Santoro-Lopes, CID 2002 Brazil 255 (0.04, 1.13) Excluded prior dx of TB Badri, Lancet 2002 South Africa 264 ARR 0.2 (0.09, 0.38) Benefit at CD4<350

Possibility of Evaluating Other Interventions Intensified TB Case Finding (ICF) Isoniazid Preventive Therapy (IPT) Cotrimoxazole Preventive Therapy (CPT) Antiretroviral therapy (ART)

Considerations for TB Surveillance in CTS Case definition of TB What data elements to collect Smear status Disease status (pulmonary vs. extrapulmonary) CD4 at TB diagnosis Previous history of TB or IPT TB treatment outcome

TB Assessment for Patients in Chronic HIV Care Suspect TB Suspect TB: Cough > 2 weeks, persistent fever, unexplained weight loss, severe undernutrition, suspicious nodes, sweats New Sm+ or Tx plan from District: treat for TB TB suspected on prior visit Active TB Suspect TB On TB tx Send 3 sputums Refer if not producing sputum or nodes No SSx, Not on tx or prophylaxis No SSx or on prophylaxis No suspicion of TB WHO/CDS/IMAI/2004.2

How/Where to Conduct? At HIV diagnosis Clinical settings (hospital, OPD) Program settings (VCT, PMTCT, prior to IPT) In HIV care and treatment settings (CTS) Clinics providing ARV Home-based care

Methodological and Logistical Issues Care interventions may increase TB rates ART may cause immune reconstitution phenomena Intensified TB case finding (vs. passive case detection) May require complicated analysis Need to ensure TB cases are notified to NTP Fewer ethical issues

Use of TB Surveillance Systems Include additional variables Source of referral Prior use of IPT Use of CPT, ART Need to have referral mechanism in place

Conclusions TB surveillance in CTS more complicated Must be considered as care and treatment programs scale up Consensus needed on methodology and approach