Isoniazid preventive therapy for people living with HIV:

Public health challenges and implementation issues

Peter Godfrey-FaussettUNAIDS

(with thanks to Lisa Nelson and Haileyesus Getahun)

IAS2013, Kuala Lumpur2 July 2013

Preventive Therapy for Tuberculosis

“Treatment of infection has been a possibility only since the introduction of isoniazid. …... its efficacy is established. It can be expected that efficacy will increase with new regimens and new drugs. Surely, the most important task ahead is social research to determine the efficient and economical ways to bring treatment to those who benefit.”

Preventive Therapy for Tuberculosis

“Treatment of infection has been a possibility only since the introduction of isoniazid. …... its efficacy is established. It can be expected that efficacy will increase with new regimens and new drugs. Surely, the most important task ahead is social research to determine the efficient and economical ways to bring treatment to those who benefit.”Ferebee, SH. Adv Tub Res 1969;17:28-106

TB is a leading cause of death among PLHIV

PLHIV Autopsy with TB (%)Cote d’ Ivore1 44USA2 33Kenya3 51Botswana4 40South Africa5 79India6 63Uganda7 37

430,000 PLHIV died of TB in 2011 (25% of AIDS deaths)

References1. Lucas et al , 1994; 2. Afessa et al, 1998; 3. Ranna et

al, 2000; 4. Ansari et al, 2002; 5. Martinson et al, 2007; 6. Lanjewar, 2011; 7. Cox et al, 2012

CFR during TB treatment with no ART

Sub-Saharan Africa1

6–39%

Thailand2,3 43-50%Cambodia4 27%Viet Nam 5,6 26-30%

References1. AIDS 2001; 15(2): 143-152; 2. J Acquir Immune Defic Syndr 2006; 43(1);’3. Emerg Inf Dis 2007; 13(7): 1001-7; 4. Int J Tuberc Lung Dis 2007; 11(9): 1008-1013; 5. Int J Tuberc Lung Dis 2006; 10: 45–51; 6. Int J Tuber Lung Dis 2006; 10(1): 45-51

IPT Reduces the Risk of TB among PLHIV

Akolo. 2010, Cochrane review

0.36

0.86

0.86

0.67

0.74

0.81

1.02

0.95

1.01.0

Lancet 2011

Cum

ulat

ive

TB in

cide

nce

IPT with ART: A Randomised Controlled Trial• HR:0.63 (95% CI 0.41-0.94)• Deaths were similar between arms (3.0% vs. 2.1%, p=0.29)• The risk of stopping IPT due to grade 3 or more raised ALT was

2.13 (95%CI 0.97-4.67)

(Rangaka et al, AIDS2012)

The 12 points policy package: What's new?

B. Decrease the burden of TB in PLHIV (Three Is for HIV/TB)5. Intensify TB case finding and ensure quality TB treatment6. Introduce TB prevention with IPT and ART7. Infection control for TB in health care and congregate settings

A. Establish the mechanisms for integrated TB & HIV services1. Set up or strengthen a TB/HIV coordinating body effective at all levels2. Conduct HIV and TB surveillance among TB and HIV patients respectively3. Carry out joint TB/HIV planning4. Conduct monitoring and evaluation

C. Decrease the burden of HIV in patients with presumptive and diagnosed TB8. Provide HIV testing & counselling to patients with presumptive and diagnosed TB9. Introduce HIV preventive methods patients with presumptive and diagnosed TB10. Provide CPT for TB patients living with HIV11. Ensure HIV prevention, treatment & care for TB patients living with HIV12. Provide Antiretroviral therapy to TB patients living with HIV

Joint HIV and TB

HIV programme

TB programme

GRC approved WHO guidelines on Three Is for HIV/TB

2009 2010 2012

Global TB screening among people living with HIV (n)

Global Isoniazid TB preventive treatment for PLHIV (n)

3.2 million

195,000

26,000

450,000

IPT was given to 1800 PLHIV in WPR in 2011 (72% from

Cambodia)

Why do we not implement an intervention with such a strong evidence base and such

strong recommendations?

• TB and HIV programme isolation

• Isoniazid is for treatment not prevention

• Fears of drug resistance• Difficulties screening

out active TB• Logistics of TST tests for

patients and providers• Juice not worth the

squeeze?

• Integrate care, coordinate management

• Cf PrEP, new regimens coming for treatment and for prevention

• Largely unjustified• Need high NPV

• Consider opt-out?

• How many people with HIV do you want to treat to prevent a case of TB?