Ukrainian TB mortality assessment 2008:

Low HIV awareness and access to ART for TB patients

associated with high HIV related TB mortality

Presenting author:Dr Anna Bobrova – National professional Officer, HIV/AIDS/STI Treatment, WHO Country Office in Ukraine

Authors:Dr Oksana Smetanina – Executive Director, Ukrainian TB Control CentreDr Inna Motrich – Chief Specialist, Ukrainian TB Control CentreDr Olena Kheylo – National professional Officer, TB/HIV, WHO Country Office in UkraineDr Gundo Weiler – Head of CDS Unit, WHO Country Office in Ukraine

HIV incidence, AIDS and AIDS mortality rates (per 100,000 of population)

43.2

40.9

9.79.5

5.85.6

05

101520253035404550

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

HIV incidence AIDS incidence AIDS mortality

TB and TB-HIV epidemic in Ukraine

77.9

13.9 12.815.4

17.5 17.7 16.6 17.7

21.8

79.883.284.1

80.977.5

75.6

68.6

60.2

54.455.3

24883

21.621.3

28.5

21.2

4.93.93.432

129.98.34.9 6.9

3.3 4.3 5 6.3

2.40

10

20

30

40

50

60

70

80

90

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

TB incidence TB mortality TB-HIV mortality

TB-HIV prevalence TB-HIV incidence

Туберкульоз в Україні аналітично-статистичний довідник 1998- 2008

WHO Report Global Tuberculosis Control 2009

Background

• TB is the leading opportunistic infection among PLWH in Ukraine

• TB is the most frequent cause of death among PLWH

• 10% of new registered TB cases are HIV positive

• TB-HIV part in TB mortality structure increased 2 times in last six years and exceeded 20% in 2009

MOH Ukraine statistic data

0%10%20%30%40%50%60%70%80%90%

100%

2004 2005 2006 2007 2008 2009

TB-HIV mortality TB mortality

TB-HIV part in TB mortality structure

Statistic data “TB in Ukraine 1999-2009”

Methods

• A retrospective analysis with questionnaires quality control

• 3 regions with over 7,500,000 population covered

• Data on 2 762 TB mortality cases in 2008 from 3 regions of Ukraine collected and analysed, 883 of which were related to HIV-TB co-infection

Results

• 64% (1 681) had a documented HIV test result

• 45% (883) of them were HIV infected• In 883 died TB-HIV patients:

– 14.8% were tested for CD4;– 1.0% were tested for viral load;– 2.4% received antiretroviral treatment.

Distribution of TB-HIV mortality cases by age and gender

0

50

100

150

200

250

300

350

400

15-17 18-24 25-34 35-44 45-54 55-64 over 65

All Male Female

Structure of TB-HIV mortality cases by TB form

97,3% (859)

2% (18 ) 0,7% (6 )

Pulmonary TB

Extrapulmonary TB

Diagnosis notregistered

Structure of TB-HIV mortality cases by MBT test result

36% (321)

5% (40)

59% (522)

Infectious TBcases

Non-infectiousTB cases

Unknown

Structure of TB-HIV mortality by TB cases

12% (110)

2% (18)19% (172)

67% (583)

Newly diagnosedcases

Relapses of TB

Chronic TB

Residual changes

HIV-infection immunological features in died TB-HIV pts

Number of cases analysed Mean CD4 count (cells/μl) p-value

All deceased TB-HIV cases with available CD4 count test result 132

139

(CI 95%,111-167)

Pts on TB treatment 124 138

0,0082Pts without TB treatment 5 23

Pts on ART 16 142

0,0169Pts without ART 103 76

Only patients for whom data regarding TB treatment, ART and CD4 count were analysed. Presented data may have limitations due to insufficient quality and completeness of HIV-related information and should not be used for references

Use of 2nd line TB drugs by categories of TB-HIV patients

Category

Numberof casesanalysed

2nd lineTB drugs

% of pts whoreceived 2ndline TB drugs

1 (new smear positive and severe cases) 469 45 10%

2 (all retreatment cases: relapses, defaults, failure) 201 29 14%

3 (new smear-negative and extrapulmonary non-severe cases) 14 0 0%

4 (MDR TB, chronic TB) 181 93 51%Other (non-active TB, autopsy, non-

classified) 18 4 22%

Total 883 171 19%

Conclusions:

• Access to HIV services (incl. laboratory monitoring of HIV-infection and ART) for TB/HIV co-infected patients in TB medical facilities remains limited

• Misuse of 2nd line TB drugs and late initiation of ART evidence inadequate level of adherence to the WHO recommendations and national TB-HIV clinical guidelines

Conclusions:

• There is a lack of coordination between TB and HIV programmes with regard to TB/HIV case management

• The situation needs considerable improvement especially regarding ART provision to TB/HIV co-infected patients