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hiv_and_tb_prevention_and_treatment.pptx

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hiv_and_tb_prevention_and_treatment.pptx

  1. 1. HIV and TB Prevention and treatment What multi-sectoral strategies will decrease the burden of infectious disease amongst the people of the Western Cape?
  2. 2. A coherent strategy needs to be informed by the answers to the following questions… • What is the scale of the HIV/TB epidemic in the Western Cape? • Where is it prevalent? • Why does it occur where it does? • What tools do we have to either prevent infection or to reduce disease severity, and how effective are they?
  3. 3. Scale and distribution of disease
  4. 4. HIV infected population in the Western Cape + ART coverage District/Sub-district No. HIV infected Proportion of total infections No. on ART Proportion of total on ART Khayelitsha 39 121 14.5% 19 708 19.1% Cape Winelands 29 371 10.9% 10 477 10.1% Klipfontein 29 205 10.8% 7 863 7.6% Eastern 26 508 9.8% 9 506 9.2% Western 22 894 8.5% 11 499 11.1% Northern 22 862 8.5% 5 385 5.2% Eden 22 271 8.2% 8 381 8.1% Mitchells Plain 17 962 6.7% 11 273 10.9% Southern 16 300 6.0% 5 764 5.6% Tygerberg 16 193 6.0% 6 147 5.9% Overberg 14 521 5.4% 3 268 3.2% West Coast 9 114 3.4% 3 570 3.5% Central Karoo 3 680 1.4% 508 0.5% 270 000 100.0% 103 349 100.0%
  5. 5. TB cases 2009 West Coast: 4,244 (8%) Central Karoo: 700 (1%) Eden: 7,204 (13%) Cape Winelands: 9,892 (18%) Cape Town: 30,820 (55%) Overberg: 3,059 (5%) 0 5000 10000 15000 20000 25000 30000 35000 Cape Town… Cape Winelands Eden West Coast Overberg Central Karoo TB cases
  6. 6. TB is the face of HIV • Being HIV-infected increases your risk of having TB by anywhere from 30 to 100-fold (depends on the stage of the HIV disease) • Proportionate to its population size, Western Cape is the province worst affected by TB TB is what is killing HIV-infected people
  7. 7. Recent HCT campaign Sites with > 1000 HIV+ tests – Red Sites with 400-1000 HIV+ tests - Yellow
  8. 8. Burden of HIV and TB ~270,000 HIV infected individuals ~50,000 diagnosed TB cases per annum Of HIV-infected people, 86% are in 14 sub-districts Of TB diagnoses, 76% are in the same 14 sub-districts These two diseases account for +/- a quarter of the years of life lost in the province
  9. 9. Because they harbour many of the risk factors associated with HIV1: The ‘deprivation cluster’ of: 1. Poverty 2. Overcrowding 3. Malnutrition 4. Migration Why do certain areas carry a disproportionate burden of HIV disease? Produce social vulnerability 1. Western Cape Burden of Disease report for major infectious diseases, 2007
  10. 10. By being strongly associated with the following risks1: 1. Not knowing one’s HIV status 2. Stigma and discrimination 3. Age mixing 4. Early sexual debut 5. Transactional sex 6. Partner turnover/concurrency 7. Alcohol misuse Social vulnerability creates a high risk environment for HIV transmission *disempowerment *compromised decision-making *economic necessity 1. Western Cape Burden of Disease report for major infectious diseases, 2007
  11. 11. Viral transmission is a complex biological sequence of events that starts with ‘permanent’ viral attachment to host epithelial tissue Some people are more likely to transmit HIV and others are more vulnerable to acquire HIV 1. Sex & age 2. Viral load 3. Sexually transmitted infections 4. Lack of circumcision 5. Mother to child transmission Despite the socio-structural environment creating a context of high risk for HIV acquisition… the final mediator of HIV transmission is biological
  12. 12. TB – another risky environment Risk 1 = Risk of being exposed to the organism (acquiring infection) • The ‘deprivation cluster’ of: impoverishment, poor nutrition, migration, overcrowded dwellings compounded by existing high TB prevalence and incidence, poor education, ignorance of TB transmission mechanisms and of TB symptoms, poor adherence to treatment “85-90% of those people with normal immunity who inhale TB do not develop disease”
  13. 13. Risk 2 = Risk of infection progressing to disease TB infection can be longstanding and “reactivate” or can be recently acquired and progressive “50-90% of South Africans are likely to be latently infected with TB” “by far the most powerful risk identified (for infection progressing to disease) is concurrent HIV infection” TB – another risky environment
  14. 14. Interventions • We’re not only trying to prevent new HIV and new TB infections • We also have a large population of people who are already HIV- infected, and in whom we are trying to prevent premature death
  15. 15. HIV prevention can and should be implemented at different levels Structural- seek to change the context that contributes to vulnerability or risk Behavioural- attempt to motivate behavioural change within individuals or communities Biomedical – attempt to block infection or reduce infectiousness
  16. 16. Biomedical interventions need to be placed into the high risk environments - at scale (and socio-structural barriers to their consistent and correct use need to be overcome) Level of intervention Risk No. Mode of action Effectiveness 1 Physical seperation 85-95% 2 Restore epithelial integrity Variable 3 Reduce epithelial vulnerabilty ~58% Oral ART- lifelong Reduce hiv in body fluids theoretically very high Oral ART- pre-coitally Reduce hiv in body fluids ~44% Topical antimicrobials peri-coitally Reduce probability of viral 'attachment' ~39% 5 Boost immunity unclear Vaccines HIV in body fluids coming into contact with epithelium of sexual partner Biomedical 4 Anti- retroviral medication Prevention method Barrier methods STI treatment Male circumcision
  17. 17. TB interventions 1. Reduce the probability of someone inhaling the mycobacterium Tuberculosis – Tackle the ‘deprivation cluster’ – overcrowding etc – Reduce prevalent and incident TB (case-finding – ART work-up, door-to-door community drives etc..) – Reduce/prevent drug-resistant TB – Reduce infectiousness of those with TB (case-treatment and case- holding) – Environmental infection control (applying not only to health facilities but all areas where people congregate – transport, work, church, bars etc)
  18. 18. TB interventions 2. Reduce the probability of inhaled (or latent) tuberculosis progressing to active disease – Early identification of high risk cases (HIV testing) and intensive education of disease symptoms – Regular routine monitoring of high risk cases – ‘Bolster immunity’: ART where indicated – IPT where appropriate
  19. 19. A word on Mother-to-child transmission Pre-conception Pre-partum Intra-partum Post-partum Antiretroviral drugs (dual and triple therapy) reduce viral load, reduce probability of transmission. The earlier started, the better Antriretroviral drugs and reducing birth trauma (C/S) Antiretroviral drugs for mother and child. Breastfeeding choices and drug cover to the child for the duration of breastfeeding MTCT – effective contraception is a powerful tool to prevent transmission of HIV from mother to child. 100% effective
  20. 20. • In the absence of a ‘game-changing’ intervention, the Western Cape will see approximately ~14,000 HIV infections in 2012 (~1,200 of which will be from mother to child) • We can identify the communities in which the ~14,000 transmission events will occur • We have the biomedical tools and knowledge to theoretically stop almost every one of those transmission events… We know the following about HIV infections in the Western Cape… But we’re missing a piece of the puzzle… And it revolves around generating large scale demand for, and consistent uptake of, proven biomedical interventions by high risk communities
  21. 21. It’s not clear how we are going to solve this vexed problem, but let’s try and picture the type of societal and community norms that would be required to reduce HIV and TB transmission…
  22. 22. What’s the “ideal world” scenario? • Structural: to do away with the ‘deprivation cluster’ • Societal/behavioural: An environment in which everybody… • Is informed of the consequences of HIV infection, knows their HIV status, checks it regularly and no stigma is attached to doing so • Uses barrier protection consistently, and especially with casual sex; has immediate access to condoms whenever they want them and their use of condoms is positively re-enforced by their partner, their peer group and their community • Delays their sexual debut and avoids having multiple sexual partners • Men present for circumcision routinely • Women use contraception consistently and space their pregnancies well • HIV-infected pregnant women know their HIV status and present very early in their pregnancy for treatment
  23. 23. What’s the “ideal world” scenario? • Societal/behavioural: An environment in which every HIV-infected person… • Knows that they are at unusually high risk of TB • Knows how to recognise TB, knows simple household and community infection control measures, knows the benefits of TB preventative therapy, knows what to do and where to go if they think they have TB • Who is HIV-infected is able to keep themselves well by routinely undergoing monitoring (for TB, cervical cancer etc) and being rapidly responsive to new symptoms
  24. 24. • Biomedical An environment in which everybody… • Has simple and rapid access to HIV and TB testing • Has easy access to required medication • Adheres to their prescribed treatment because they understand it benefits them, are aware of the consequences of not doing so, and are supported in doing so by their peers and their community What’s the “ideal world” scenario?
  25. 25. • “Highly active HIV prevention inevitably must be combination prevention” • “Nothing should be more important than a focus on young people” • “investments should focus on promoting normative and social change to reduce multiple and concurrent partnerships, and to greatly increase availability of safe and affordable male circumcision services” • “condoms (unlike contraception) have to be available immediately and thus a continuous source of supply is needed” • “The aggregate effect of radical and sustained behavioural changes in a sufficient number of individuals potentially at risk is needed for successful reductions in HIV transmission” “ Understand but don’t overcomplicate. Broad rapid brushstrokes are sufficient for action” UNAIDS suggested high level strategies…

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