1. HIV/TB Integration in a Network of Voluntary Counseling/Testing Centers in HAITI Reynold Grand’Pierre MD, Marie Suze Jacquet MD, Jean W. Pape MD PEPFAR Meeting Kigali, Rwanda June 16, 2007

3. Timeline of HIV Disease in Haiti Before ART: Most important OIs Pulmonary TB : most common pre-AIDS manifestation occurring in 40% of the cohort by 6 years Most common AIDS illness: wasting syndrome, candida esophagitis, coccidia diarrhea Leading causes of death : wasting syndrome, TB, crytococcal meningitis, toxoplasmosis Deschamps MM et al. AIDS. 2000, 14:2515-2521

4. STI Management Post-HIV exposure Counseling and HAART Pre-test Counseling HIV, Syphilis, Tuberculosis, Malaria Post-Test Counseling Same day TB screening / Rx / Px Care to HIV infected individual / affected family  OI Rx/Px  HAART for AIDS or CD4 count  200  Nutritional support  Psychosocial support Reproductive Health Services (family planning and prenatal care) HIV+ women Prevention HIV MTCT with HAART Cornell-GHESKIO VCT model with integrated services Rx = Treatment Px = Prophylaxis Peck R, Fitzgerald D, Liautaud B et al: JAIDS:33;470-475, 2003

5. PIH “Zanmi la sante” GHESKIO Centers National Plan for Expansion of Care and Prevention 2005-2006

6. Screening for TB at HIV VCT Centers Study to evaluate risk of having TB among clients with cough seeking HIV testing at voluntary counseling and testing centers (VCTs). Active TB was diagnosed in: –30% of all VCT clients presenting with cough  Essential to offer same day screening for TB for persons with cough at HIV VCT centers  Patients with TB and cough can be rapidly identified for:  Treatment and  Prevention of TB transmission to immuno-compromised patients in waiting rooms  Patients dually infected with TB and HIV can be placed on isoniazid prophylaxis to prevent active TB Burgess A et al, AIDS:15: 1875-1879 2001

7. Screening of adults with cough for TB at GHESKIO VCT YEARN Screened for HIV N with Cough N with TB 20019,7431,251294 200212,1101,573394 200315,8082,003509 200417,4111,672625 200517,4821,544502 TOTAL72,5548,0432,324 30% of all with cough have active TB30% of all with cough have active TB 55% of active TB cases are HIV+55% of active TB cases are HIV+

8. HIV seroprevalence in TB and non-TB Adult Patients in MOH-GHESKIO Network in 2006 TB Centers % HIV+ VCT centers % HIV+ NETWORK232/116820.05348/4983011.0 GHESKIO290/61047.53549/2379715.0 TOTAL522/179829.08897/7372712.0

9. Tuberculosis prevention in persons co-infected with HIV and TB Rate of active tuberculosis cases per 100 person-years PlaceboIntervention Author/Place/Date Pape et al/Haiti/1993 INH, X 1 year101.7 Markowitz et al/USA/1997 INH, X 6 mo4.71.6 Whalen et al/Uganda/1997 INH, X 6 mo3.411.08 INH+RIF, X 3 mo3.411.32 INH+RIF+PZA, X 3 mo3.411.73 Halsey et al/Haiti/1999 INH, 2X/week, X 6 mo-1.0 RIF +PZA, X 8 weeks-3.7 INH = Isoniasid ;RIF = Rifampin; PZA = Pyrazinamide

10. Effect of preventive INH on the incidence of active and progression of HIV infection Pape JW et al: The Lancet 342: 1993

11. MDR-TB et VIH Primary TBRecurrent TB HIV+11/115 (10%)- HIV-5/166 (3%)- RR=3.2, p=0.03 TOTAL16/281 (6%)10/49 (20%) 330 strains of mycobacterium tuberculosis during a 2 year period Joseph, P et al, AIDS 2006, 20:415-418 In collaboration with Institut Pasteur de Guadeloupe

12. Outcome of integration of HIV and TB From January 2005 to December 2006 in the MOH-GHESKIO network: At VCT centers: – 9199 HIV-infected patients were evaluated for TB; 2395 (26%)of them received care for TB –2126 patients HIV positive received INH prophylaxis 3768 patients with tuberculosis were tested for HIV; –1213 (32%) of them were HIV positive

13. HIV/TB Challenges for Haiti Interactions HIV/TB –HIV rate is 2-4 X higher in TB patients –Risk of developing active TB is 10X higher in HIV+. –INH prophylaxis and ART are both effective to prevent active TB in HIV+ TB diagnosis : majority of TB patients are smear negative. Must do CXR Most TB centers are staffed by nurses and auxiliary nurses ART and TB therapy is complex –Preferable not to start HIV and TB therapy at the same time to avoid IRS –High toxicity, mortality; abandon rate, recurrence rate MDRTB: higher association with HIV+  Necessity to develop joint HIV/TB national programs 1) Necessity to screen for HIV in all TB centers and 2) Screen for TB at VCT centers.  HIV+ and PPD+ should have a CXR and sputum smear to rule out active TB  Place on TB therapy those with active TB and on INH those who do not have active TB  HIV+ should receive INH + RIF during entire duration of therapy 3) Develop joint ART/TB training for care of HIV + patients requiring both 4) Need to develop new category of medical staff: Physician assistant 5) Must develop effective referral system between HIV and TB centers 6) Need to have nationwide survey on importance of MDRTB and new centers to care for MDRTB

14. Perspectives Complete integration between the national HIV and TB programs is necessary to curb both epidemics. With PEPFAR support, plan to create at a public TB site (Siguenau): –Unit for HIV/TB management –Unit for MDRTB treatment