1. Annabel Baddeley Global TB Programme WHO, Geneva
Increasing access to integrated TB services for people who inject drugs
First of all I would like to thank the organisers for providing the opportunity to give this presentation on TB and drug use.
Annabel Baddeley
Global TB Programme
WHO, Geneva

2. Outline of presentation
Global burden and evidence
Highlights of TB/HIV recommendations in the updated WHO, UNAIDS and UNODC policy guidance
Conclusion
In my presentation I will review the evidence to show the magnitude of TB among people living with HIV and who use drugs and will provide an overview of the WHO, UNAIDS and UNODC policy recommendations on how to address TB among people who use drugs, discuss the challenges and conclude.

3. PWID with HIV at higher risk of TB
Factors associated with tuberculosis as an AIDS-defining disease
Risk Group % OR
95%CI
Adjusted OR
95% CI
MSM
18.2 1
IDU
40.8
3.10
2.58
Heterosexual
26.5
1.63
1.96
Unknown
17.7
0.97
1.01
(Barcelona ), Martin V et al J Epidemiol 2011 ;21 (2) :
Association between drug use and MDR-TB
TB is the most common AIDS defining illness in European drug users and this is confirmed by findings from a study in Barcelona by Martin et al that showed that IDU’s with HIV were 2.58x the risk of getting TB than MSM. Pre-AIDS era studies from New York have PUDS10 times more at risk of TB (without HIV).
MDR-TB almost double in prisons than in civilian population.
Factors associated with tuberculosis as an AIDS-defining disease (Barcelona ) Martin V et al J Epidemiol 2011 ;21 (2) :
Post et al, Journal of Infection (2014) 68, , (Belarus, Latvia, Romania, Russia & Ukraine)

4. Lower survival of TB patients who inject drugs
This study done among almost 800 TB patients from Barcelona showed that TB patients who inject drugs have an increased risk of mortality after starting TB treatment.

5. 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 ( )
HCV
22/187
11.8 ( )
HIV
35/205
17.1 ( )
Source: Pando et al Journal of Medical Microbiology (2008), 57,
Getahun et al, Curr Opin HIV AIDS 2012;7:

6. Drug use, TB, HIV, Hepatitis and incarceration
Up to 74% prisoners injected and up to 94% shared equipment while in prison1
78% PWID reported history of incarceration and 30% injected while in prison2
PWID & ex-PWID 5 times more at risk of TB/HIV after 23 months in prison than at time of admission3
PWID with history of imprisonment 3 times more at risk of HCV2
J Epidemiol 2011;21(2):
The IDU/incarceration linkage leads to further complexities in stigma, access and continuity of care – as well as drug resistant strains
10 country study – all cities in western Europe: Seville and
Granada, Spain; Cologne, Germany; Vienna, Austria;
Brussels, Belgium; Athens, Greece; Dublin, Ireland;
London, England; Lisbon, Portugal and Perugia, Italy
The risk of TB infection and disease is consistently higher among prison inmates than among the general population, and this increases with the length of detention
The risk of MDR-TB in prisoners found to be around double the rate of the civilian population - RR 1.8 (1.5–2.2)4
Jürgens et al, Lancet Infec Dis 2009;9:57-66 (Australia)
Hayashi et al, BMC Public Health 2009, 9:492 doi: / (Thailand)
Martin et al, INT J TUBERC LUNG DIS 4 (1):41-46 (Spain)
March JC et al. Enferm Infecc Microbiol Clin 2007;25(2):91-7 (Spain, German, Austria, Belgium, Greece, Ireland, England, Portugal and Ireland)

7. Challenges and barriers to access
Multiple morbidities and drug-drug interactions
Structural barriers
Criminalization and unsupportive legislative environment
Silo service provision and lack of collaboration
Mandatory hospitalisation of TB patients in some countries
Stigma, discrimination and violence against PWID
Limited data and lack of ownership
Low on the list of competing priorities
People living with HIV who use drugs show increased frequencies of side-effects and toxicities from tuberculosis and antiretroviral treatments, probably resulting from the high prevalence of hepatic, renal, neurological, psychiatric, gastrointestinal and haematological comorbidities in IDUs. Outcomes of tuberculosis treatment are less favourable in HIV-infected drug users than in other populations. Apart from the previously noted challenges, problems in health-care structure and patient behaviour can confound treatment success
Increased stigma associated with multiple comorbidities and reluctance of people who use drugs to use traditional health-care settings often result in delayed entry into care and treatment.

8. Policy guidelines updated and consolidated

9. Key components Composition of multi-sectoral coordinating body
Multisectoral coordination and joint planning
Integrated patient-centred care
TB screening, prevention and care
HIV testing, prevention and care
Management of other co-morbidities, including viral hepatitis B and C
OST and other evidence based drug dependence treatment including Naloxone
Adherence support
Community engagement
Equivalence of health-care for prisoners
Addressing structural barriers
UPDATE
IN 2014
To establish and strengthen mechanisms for inter-service and multi-sectoral collaboration for the integrated management of TB, HIV and viral hepatitis in people who inject drugs
TB/HIV coordinating mechanisms to facilitate integrated delivery of TB, HIV and narcology services within the same facilities, including prisons.
Civil society engagement to improve access to integrated TB/HIV and harm reduction services.
Expand access to evidence-based harm reduction services including TB, and HIV prevention, diagnosis and treatment for people who inject drugs.
HIV services to implement intensified TB case-finding, TB infection control and isoniazid preventive therapy (IPT)
Xpert MTB/RIF recommended as the first TB diagnostic test to detect TB among PLHIV or for suspected MDR-TB
TB services to offer HIV testing and counselling to all people with presumptive or diagnosed TB, and provide co-trimoxazole preventive therapy and antiretroviral therapy
ART for all PLHIV with TB, irrespective of CD4 count, within 2-8 weeks of TB treatment initiation
A1 Set up and strengthen a coordinating body for integrated delivery of services for PWID,
A2 Determine HIV and TB prevalence among PWID.
A3 Carry out joint planning for the integrated delivery of services for PWID.
A4 Integrate the monitoring and evaluation of collaborative TB/HIV activities into services providing drug dependence treatment and care
To reduce the joint burden of TB, HIV and viral hepatitis among PWID through the integrated delivery of comprehensive services;
B1 Define client-centred models of integrated service delivery for PWID
B2 Increase access to collaborative TB/HIV activities
B3 Ensure access to opioid substitution and other drug dependence treatment
B4 Manage other co-morbidities, including viral hepatitis B and C
To ensure equivalence of health in prisons through the harmonization of interventions.
Composition of multi-sectoral coordinating body
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
Models of service delivery
Holistic person centred way that maximize access and adherence where possible in one setting.
Adherence
Specific adherence support measures for drug users including:
Supervised therapy
linkage to Opioid Substitution Therapy,
Adherence counselling
adherence reminders
contingency management
ancillary services
Common Co morbidities
viral hepatitis infection should not be considered a contraindication to HIV or TB treatment for drug users.
Prisons
equivalence of care for prisoners with civilians and continuity of care on transfer in and out of prison.

10. Combination TB prevention
Studies
IPT alone
ART alone
ART plus IPT
Brazil 68 52 80
South Africa 13 64 89
Botswana 65 67 97
AIDS 2007: 21: ;
AIDS 2009, 23:631–636;
Lancet 2011: 377:
Several studies showed that for people living with HIV, ART is actually a potent TB preventive treatment reducing risk of TB between 54-92%.
All TB patients no matter whether they use drugs or not should receive ART as soon as possible regardless of their CD cell counts.
Another important recommendation of the TB/HIV drug use guidelines is that comorbidity, including viral hepatitis infection (such as hepatitis B and C), should not contraindicate HIV or TB treatment for drug users. Alcohol dependence, active drug use and mental health problems should not be used as reasons to withhold TB and HIV treatment.
Infection control in treatment facilities, drop-in centres, prisons and other congregate settings

11. TB screening and isoniazid preventive therapy (IPT) for PWID living with HIV
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 ( )
Clinical 89 30
98.3 (
CD4 < 200 94 22
98.9 ( )
CD4> 200 83 34
96.9 ( )
Another important recommendation is about the TB screening and the provision of isoniazid preventive therapy.
In a recent primary meta-analysis we conducted among more than 8000 people living with HIV we identified having
Getahun et al PLoS Medicine 2011
Symptom based TB screening is sufficient to exclude TB among PLHIV who use drugs and provide at least 6 months IPT

12. New diagnostics
Xpert MTB/RIF should be used rather than conventional microscopy, culture and DST as the initial diagnostic test in adults suspected of having MDR-TB or HIV-associated TB (strong recommendation, high-quality evidence).
In high HIV and TB burden settings

13. Treatment for HIV-associated TB
PWID living with HIV-related TB should receive ART within 8 weeks after start of TB treatment, regardless of CD4 count;
Stable care with support for drug dependence results in successful outcomes;
OST should be offered with TB, hepatitis or HIV treatment for opioid dependent patients;
No need to wait for abstinence from opioids to commence either anti-TB medication, treatment for hepatitis or antiretroviral medication
Co morbidities, including viral hepatitis infection (such as hepatitis B and C), should not contraindicate HIV or TB treatment for people who use drugs

14. Conclusion
Multi-sectoral and cross service coordination is vital for preventing, diagnosing and treating TB and HIV in people who inject drugs.
Prisons should not be addressed in isolation.
Removal of structural and legal barriers to allow integrated comprehensive harm reduction are key to increasing access to care for PWID.
Prompt accessible prevention, diagnosis and treatment of TB, HIV and drug dependence among PWID saves lives.

15. Documented examples of integration
A rapid assessment of the accessibility and integration of HIV, TB and harm reduction services for people who inject drugs in Portugal, final study report, April 2012
4 country study of the implementation of collaborative TB and HIV services for drug users, Brazil, India, Ukraine, Zanzibar, 2010
Case study on building integrated care services for injection drug users in Ukraine