1. T UBERCULOSIS

2. P HYSICAL ILLNESS Physical illness among IDUs is more common as compared to the general population A Study from Chennai conducted in 2005 – 06 showed increased rates of physical illness (Solomon et al, 2008) The same group also showed that mortality is more in comparison with the following causes: Overdose, AIDS, tuberculosis, accident (Solomon et al, 2009) IllnessPrevalence / rate (%) Tuberculosis33.9 Lower respiratory tract infections 16.1 Anaemia22.9 Hepatitis B11.9 Hepatitis C94.1 Cellulitis6.8 Herpes simplex9.3 Herpes zoster9.3 Oral candidiasis43.2

3. P HYSICAL ILLNESS – REASONS Both drug use and physical illness may be caused by overlapping factors leading to both illnesses E.g. genetic factors, stress related factors Drug use and TB may be caused by the individual living in poor socio- economic conditions Common vulnerability factors Drug use Physical illness

4. T UBERCULOSIS Tuberculosis (TB) is caused by a microscopic organism – bacteria – mycobacterium tuberculosis Can affect any body part Usually affect lungs Other sites: lymph nodes, bone, brain, spinal cord, genital-urinary system, etc. TB causing bacteria

5. T UBERCULOSIS TB is contagious and spreads through air Transmitted from one person to another through droplets When an infected person sneezes, coughs or talks, tiny droplets of saliva/mucus spread to another person, who can get infected If not treated, each infected person with active TB will infect 10 – 15 person every year TB is not transmitted by touching clothes or shaking hands of an infected person

6. T UBERCULOSIS Inhaled by another Person Entry into his lungs Strong immune system Low immune system Tuberculosis disease Fibre wall around the bacteria If low immunity Bacteria breaks the wall Droplet spread

7. T HE OVERLAP BETWEEN TB, HIV AND INJECTING DRUG USE IDU 15.9 million HIV 33.4 million TB 11.1 million 3 million ? 1.4 million ? Mathers et al. Lancet, 2008. WHO 2009

8. T UBERCULOSIS Risk factors for tuberculosis Injecting Drug Users Diabetes Certain cancers HIV infection Health care workers, including doctors and nurses Living with a person who has an active TB Poverty Homelessness Nursing home residents Prison inmates Alcohol dependents

9. W HO IS AT RISK ? People who are co-infected with HIV and TB are 21 to 34 times more likely to become sick with TB Risk of active TB is also greater in persons suffering from other conditions that impair the immune system Tobacco use greatly increases the risk of TB disease and death. More than 20% of TB cases worldwide are attributable to smoking

10. R ISK OF ACTIVE TUBERCULOSIS People infected with TB bacteria have a lifetime risk of falling ill with TB of 10% However persons with compromised immune systems, such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a much higher risk of falling ill

11. T UBERCULOSIS Symptoms of active tuberculosis Coughing up of sputum Coughing blood Shortness of breath If other systems involved, symptoms according to the function of the organ – E.g. Brain: fits, unconsciousness Generalised tiredness/weakness Weight loss Fever Night sweats Cough Chest pain

12. D ETECTING T UBERCULOSIS Diagnosis is based on a long-used method called sputum smear microscopy Trained laboratory technicians look at sputum samples under a microscope to see if TB bacteria are present With two or three such tests, diagnosis can be made within a day, but this test does not detect numerous cases of less infectious forms of TB Diagnosing MDR-TB (Multidrug-resistant TB) and HIV- associated TB can be more complex

13. T UBERCULOSIS Diagnosis based on Symptom profile and Sputum examination Treatment Nearest TB centre under RNTCP Directly Observed treatment (DOT) Person becomes non-infectious within 3 weeks of initiating treatment

14. T UBERCULOSIS D ELAY IN TREATMENT When a person develops active TB (disease), the symptoms (cough with sputum and blood at times, chest pains, weakness, weight loss, fever and night sweats) may be mild for many months This can lead to delays in seeking care, and results in transmission of the bacteria to others People ill with TB can infect up to 10-15 other people through close contact over the course of a year Without proper treatment up to two thirds of people ill with TB will die

15. Treatment of Tuberculosis Six months treatment Two months of intensive treatment with Rifampicin, Isoniazid, Pyrizanamide and Ethambutol followed by four months of continuation phase with Rifampicin and Isoniazid First line anti-TB drugs

16. T UBERCULOSIS Other important considerations TB is the leading killer of people with HIV HIV infected people are 20 – 40 times more likely to develop active TB TB has resurfaced in the global epidemic because of the onset of HIV infection Multi drug resistant TB (MDR-TB): form of TB that is difficult and expensive to treat which fails to respond to standard treatment Extensively drug resistant TB (XDR-TB): form of TB which is resistant to drugs used in MDR-TB

17. T UBERCULOSIS IDU related issues for TB IDUs have a very high rate of TB Reasons are many – poverty, homelessness, poor living conditions, low immunity, poor nutrition, high HIV rates Early symptoms of TB may be mistaken for other conditions. For example Weight loss, weakness or tiredness  general debility Cough, chest pain  chronic bronchitis associated with co- morbid smoking

18. T UBERCULOSIS During every follow up, symptoms of TB must be positively ruled out Baseline screening must be ensured by the counsellor by referral to the physician Clients should be educated on signs/symptoms of TB Clients with symptoms resembling TB must be referred to nearby DOTS centre For those on treatment for TB: counselling for adherence, physically verify whether the client is taking TB medicines or not

19. T REATMENT OF TUBERCULOSIS IN I NJECTING DRUG USERS TB treatment adherence can be increased among injecting drug users by close monitoring and supervision Adherence to treatment is facilitated by opioid substitution therapy and IDUs on OST adhere to TB treatment as well as others It is possible to organise TB- DOTS in OST clinics There is interaction between methadone, a substitution drug and rifampicin In view of the drug interactions, it may be necessary to adjust the methadone dose in people who also receive rifampicin ( methadone dose may be increased to reduce withdrawals)

20. R EDUCING TB BURDEN AMONG PEOPLE LIVING WITH HIV: WHO, 2008 The Three “I”s to reduce the burden of TB disease among people living with HIV Intensified case finding (ICS) Isoniazid preventive therapy (IPT) TB Infection control for people living with HIV (IC)

21. D ECREASING THE BURDEN OF HIV IN IDU S WITH TB Provision of HIV testing and counseling Introduce HIV prevention methods Introduction of co-trimoxazole preventive therapy among eligible PLHIV Provision of HIV and AIDS care and support Provision of antiretroviral therapy

22. K EY MESSAGES TB co infection is very common in HIV infected IDUs All HIV positive IDUs should be screened for TB Decreased adherence and low access to the health care system should be managed Rifampicin decreases methadone concentration and produce withdrawal symptoms