The impact of ART for HIV on TB - WHO10 1 0.1 450 275 100 450 275 100 450 275 100 450 275 100 Italy...
Transcript of The impact of ART for HIV on TB - WHO10 1 0.1 450 275 100 450 275 100 450 275 100 450 275 100 Italy...
The impact of ART for HIV on TB
Brian Williams
South African Centre for Epidemiological Modelling and Analysis
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Italy Italy Italy CapePPD-neg. Anergic PPD-pos. Town
CD4 cell counts/μL
Inci
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e of
TB
(%/y
ear)
Incidence of TB increases at 0.36 per 100 CD4/μL.
Antonucci JAMA 1995; Badri Lancet 2002
Lawn SD, Myer L, Edwards D, Bekker LG, Wood E. Abstract 788: CROI 2009
Rate of increase: 0.42 ± 0.17 per 100 CD4+ cell counts per μL.
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Ann
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. HIV- HIV+
TB incidence among gold miners in SACorbett EL Stable incidence rates of tuberculosis (TB) among human immunodeficiency virus (HIV)-negative South African gold miners during a decade of epidemic HIV-associated TB. J Infect Dis. 2003;188: 1156-63.
To fix δ we used the model for South Africa to find the value of δ that fits the average disease duration ratio for South Africa
The model fits the data without ART
TB notification rates in South Africa
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Given the epidemic of HIV, we then have one global parameter (δ ) and two country specific parameters (I0 and C0).
C0 ≡ Rate of increase of TB incidence with time
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A B C D E F
The TB epidemic in South Africa. A to C without ART; E to G with testing and immediate ART. A and D: d = 0; B and E; d = 0.60; C and F; d = 1.0.
CD4 cell counts/μL from published surveys and estimated in this study
Survey This model
Botswana 626 ± 26 666 ± 40South Africa 1179 ± 36 964 ± 35Tanzania 911 ± 38 1201 ± 28Zambia 840 ± 60 1189 ± 26
Study number
IRR
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f AR
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Incidence rate ratio for TB among people on ART and not on ART. Heavy red line: weighted geometric mean.
1. Low income countries; 2. High income countries; 3. South Africa 4. Europe; 5. Europe and North America; 6. Europe and North America; 7. Europe and North America; 8. Brazil; 9. Italy.23 10. Brazil; 11. Spain; 12. United States; 13. Europe; 14. Brazil.
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TB in South Africa: test and treat immediately
Impact on TB of testing people in South Africa once a year for HIV and starting them on ART at different CD4 levels
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Time since seroconversion (years)
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+TB
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AIDS related TB in South Africa
IR
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IR
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TB notifications/100k HIV prevalence in adults
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Gabon
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Need…• Models structured by age and gender
• Much better data on the extent to which ART reduces the incidence of TB
• Much better understanding of the role of CD4 cell counts in determining the risk of TB
• Data on the relative risk of latent breakdown and new infection
• Carefully monitor trends in TB incidence as ART coverage is increased
Time to death (years)
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ART drives CD4 back up
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Williams BG et al. J Infect Dis. 2006;194:1450-8.CASCADE Collaboration Lancet. 2000;355:1131-7.
Falling epidemic
Rising epidemic
SS+ TuberculosisPrevalence Incidence Disease Duration
(%) (%/yr) (yr)HIV+ 0.44 (0.02-1.05) 2.87 (1.94-4.25) 0.15 (0.05-0.48)HIV- 0.55 (0.14–0.95) 0.48 (0.27-0.84) 1.15 (0.48-1.13)
DDR = 0.13 (0.09–0.20)Gold miners in South Africa
We define disease duration as prevalence divided by incidence
But: Robin Wood finds 1.12.
Liz Corbett
Reduction in TB incidence over 20 years among HIV-positive people as a function of effective coverage and the CD4 count/µL at which people start ART. ART reduces the incidence of TB to the level immediately after sero-conversion.
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1980 1990 2000 2010 2020 2030 2040
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0.00
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0.04
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1980 1990 2000 2010 2020 2030 20400.000
0.005
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0.015
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vale
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d m
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0.35
1980 1990 2000 2010 2020 2030 20400.000
0.010
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Zimbabwe
HIV TB IRR
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