1. Sanghyuk Shin, PhD Department of Epidemiology UCLA Fielding School of Public Health Aug 27, 2015 Tuberculosis and HIV Co-infection: “A Deadly Syndemic”

2. Photograph: Union Rescue Mission (www.urm.org) LA County Homeless Estimated 60,000 in LA County 5000 in downtown Skid Row TB outbreak 92 cases since 2007 16 deaths (17%) 21% HIV infected TB Outbreak among Homeless Persons in LA County

3. 1. Background on Tuberculosis 2. Impact of HIV on TB epidemic 3. TB and HIV among LA County homeless persons Outline

4. Tuberculosis Background

5. CDC Division of Tuberculosis Elimination website at http://www.cdc.gov/tb Active Tuberculosis Disease Symptoms

6. TB infection and disease

7. Active TB disease due to new infection

8. TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection

9. TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection Active TB disease due to reactivation of old infection

10. TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection Active TB disease due to reactivation of old infection 90% never develop disease

11. Detection of TB infection Tuberculin skin test (TST or PPD) 2-3 days

12. Detection of TB infection Tuberculin skin test (TST or PPD) Blood tests -T.Spot -QuantiFERON 2-3 days

13. Detection of TB disease Symptoms Sputum microscopy Chest X-ray Culture Molecular tests

14. Tuberculosis Treatment At least 6 months of drug therapy  Coughing and symptoms stop after 2 months Treatment = prevention  Prompt diagnosis  Completion of appropriate treatment

15. Trends in incidence of active TB WHO, Global Tuberculosis Report 2014

16. Multi-drug resistant TB (MDR-TB) Extensively drug resistant TB (XDR TB) Drug-resistant TB Major global health threat

17. TB/HIV co-infection

18. “A syndemic is a set of intertwined and mutually enhancing epidemics involving disease interactions at the biological level…” Singer 2003 Medical Anthropology Quarterly TBHIV

19. http://www.askdatasystems.com/EPIDEMI/ep/epimod1.htm

20. Drivers of TB Epidemic http://www.askdatasystems.com/EPIDEMI/ep/epimod1.htm

21. Drivers of TB Epidemic http://www.askdatasystems.com/EPIDEMI/ep/epimod1.htm HIV!!!

22. TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection Active TB disease due to reactivation of old infection Never develop disease

23. TB infection and disease Latent TB infection (LTBI) Active TB disease due to new infection Active TB disease due to reactivation of old infection Never develop disease HIV!!!

24. TB/HIV co-infection TB leading cause of death in PLHIV PLHIV infected with TB 20-40 times more likely to develop active TB. 80% of all TB/HIV cases are in Africa

25. WHO, Global Tuberculosis Report 2014 HIV Prevalence among TB Cases, 2013

26. Kwan 2011 Clinical Microbiology Reviews “Excess” TB due to HIV in the US

27. Tuberculosis Treatment outcomes WHO, Global Tuberculosis Report 2014

28. TB and HIV among LA County Homeless Persons

29. Photograph: Union Rescue Mission (www.urm.org) LA County Homeless Estimated 60,000 in LA County 5000 in downtown Skid Row TB outbreak 92 cases since 2007 16 deaths (17%) 21% HIV infected Outbreak among Homeless Persons in LA County

30. Drivers of TB Epidemic http://www.askdatasystems.com/EPIDEMI/ep/epimod1.htm HIV!!!

31. TB among Homeless Persons in the U.S. Bamrah 2013 International Journal of Tuberculosis and Lung Disease TB Rates 10-fold higher More likely due to recent infection Delayed detection and treatment Poor completion of treatment High mortality Substance use HIV co-infection 2-3x higher

32. “TB is the classic disease of poverty, and a classic case study of the impact of social conditions on disease.” Rasanathan et al. The social determinants of health: key to global tuberculosis control. INT J TUBERC LUNG DIS 15(6):S30–S36; 2011.

33. Historical trends

34. TB Prevalence Lowest vs. Highest Socioeconomic Status Lönnroth K. Risk factors and social determinants of TB. North American Regional Conference of the Union. Feb 24, 2011. Vancouver, BC, Canada.

35. New TB cases by Race/Ethnicity in the U.S. Scott et al. 2015 MMWR

36. TB Rates by Income among Foreign-born Persons in the U.S. Olson 2012 BMC Public Health

37. What Can Be Done to Reduce TB Burden in Low-Income Communities?

38. Healthcare-related  Community health workers/peer health counselors  Mobile health clinics  Increase clinic hours  Travel vouchers  Free universal health insurance Social interventions  Housing  Financial support  Social welfare programs  Improved working conditions Hargreaves JR, Boccia D, Evans CA, Adato M, Petticrew M, Porter JD. The social determinants of tuberculosis: from evidence to action. Am J Public Health. 2011 Apr;101(4):654-62. Interventions to overcome socio- economic barriers for TB/HIV

39. TB/HIV Co-infection Conclusions TB/HIV co-infection is a major public health concern HIV is the strongest known risk factor for TB disease HIV has had enormous impact on TB epidemiology Poor and marginalized communities most affected Interventions must address social conditions

40. Thank You! Photos from 1) Airborne: a journey into the challenges and solutions to stopping MDR-TB and XDR-TB / by John Donnelly. World Health Organization 2009, and 2) WHO Commission on Social Determinants of Health. Closing the Gap in a Generation. 2008