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สาระพนัความรูเ้ก ีย่วกบัIPTพญ.พัชร ี ขนัตพิงษ์THE 2ND NATIONAL QI FORUMFOR HIV, TB AND STIS2 ส.ค. 2559

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IPT

Treat Latent TB Infection

• 1993 WHO/UNAIDS : IPT for PLWH

• 2004 WHO : Strategy “3Is for HIV/TB”

• 2003 IPT first time in National guideline: The integrated TB/HIV strategies for the control and prevention of TB in Thailand

• Revised 2005, 2008 by Thailand MOPH

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IPT/TLTI

• คอือะไร

• มปีระโยชนอ์ยา่งไร

• ใหใ้ครบา้ง

• ใหอ้ยา่งไร

• ใหเ้มือ่ไหร่

• Program Implementation

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IPT / TLTI

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INH/TLTI

Dx Latent TB Infection

• positive tuberculin skin test (TST)

• interferon gamma release assay (IGRA)

+ Asymptomatic

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TST

1.HCW -How to do Give 0.1 ml of 5 Tuberculin Units PPD intradermally

-Tests should be read between 48 and 72 hours - TST positive > 5 mm in HIV+

2. Supply chain3. Patients : Counselling, adherence, adverse drug reaction

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IPT มปีระโยชนอ์ยา่งไร

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TB Rates in HIV+ Patients With Access to ART and IPT in Rio de Janeiro

Exposure category

Person-Years

TB cases IR

(per 100 PYs)IRR

Naïve 3,865 1553.98

(3.38-4.67)1.0

HAART only

11,627 2211.91

(1.67-2.18)

0.48

(0.39-0.59)

IPT only 395 51.27

(0.41-2.95)

0.32

(0.10-0.76)

Both 1,253 100.80

(0.38-1.47)

0.20

(0.09-0.91)

TOTAL 17,142 3912.28

(2.06-2.52)

Golub et al., IAC Toronto, 2006

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Tuberculosis Preventive Therapy in the Era of HIVInfection: Overview and Research PrioritiesGavin J. Churchyard,1,2,3 Fabio Scano,4 Alison D. Grant,3 and Richard E. Chaisson51Aurum Institute for Health Research, Marshalltown, and 2Centre for AIDS Programme of Research In South Africa (CAPRISA), Universityof KwaZulu Natal, Durban, South Africa; 3London School of Hygiene and Tropical Medicine, London, United Kingdom; 4Stop TB Department,World Health Organization, Geneva, Switzerland; 5Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland

JID 2007:196 (Suppl 1)

Efficacy of tuberculosis (TB [includes confirmed, probable, and possible active cases of

TB]) preventive therapy (with any drug), compared with placebo, in reducing the incidence

of active TB. “Death” denotes death due to all causes.

Gavin J Churchyard et al. J Infect Dis. 2007;196:S52-S62

© 2007 by the Infectious Diseases Society of America.

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TB incidence reduction

-36% Regardless of TST status

-62% in positive TST

Efficacy of all TB Preventive Therapy

Efficacy of isoniazid (INH) preventive therapy, compared with placebo.

Gavin J Churchyard et al. J Infect Dis. 2007;196:S52-S62

© 2007 by the Infectious Diseases Society of America.

given for 6–12 mos, reduced the TB incidence

• 33% overall

• 64% among TST positive

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Isoniazid (INH) alone

Guideline of IPT for PLWH in Chiangrai

PLHIV without active TB Disease

IPT

Tuberculin (PPD)

skin test

Not Enroll IPT

> 5 mm.

-Individual and group counseling INH to ensure taking INH 9 months

- INH(100mg) 3x1 : 9 months

- Vitamin B6 1x2 : 9 months

- Follow up monthly

Routine follow up

every 6 months

< 5 mm.

Response by AIDS section

CXR

Sputum AFB x 3

CD4 กบัปฏกิริยิาทเุบอรค์ลูนิ(TST)

CD4 TST < 5 TST > 5

0-200 (N=761) 703 (92%) 58 (8%)

201-500(N=616) 517 (84%) 99 (16%)

501 (N=283) 216 (76%) 67 (24%)

Total (N=1660) 1436 (87%) 224 (13%)

Outcome of IPT

Complete: 9 months

Died; within 9 months

Default: lost to follow up more than 2 months

Failure: become to active TB within 9 months

Severe Adverse Reaction(side effect)

Transfer out

7582.284.185.5

8056.8

35.739.3

46.552.9

61.857.9

55.6

58.2

4.37.2

13.323.4

31.742.6

41.733.7

28.933.4

31.8

0% 20% 40% 60% 80% 100%

2006

2005

2004

2003

2002

2000

1999

1998

1997

1996

1995

1994

1993

COMP FAIL DEFA DIED SEFF OTHE TOUT ONTX

Treatment outcome of IPT program in Chiangrai Province, 2002-2006

อบุตักิารณ์การเกดิวณัโรคในผูต้ดิเชือ้เอชไอว ีทีไ่ดร้บัและไมไ่ด้รบั INH เพือ่รกัษาการตดิเชือ้วณัโรคแฝง (TLTI) ( PLHIV cohort study in 8 hospitals by RIT)

Total TB

case

Incidence Rate

per 100 person year

อบุตักิารณ์การเกดิวณัโรคในผู ้ทีไ่มไ่ดร้บัยา INH

1483 164 3.08

อบุตักิารณ์การเกดิวณัโรคในผู ้ท ีไ่ดร้บัยา INH กอ่นเขา้โครงการ

162 5 0.62

อบุตักิารณ์การเกดิวณัโรคในผู ้ท ีไ่ดร้บัยา INH หลงัจากเขา้โครงการ

228 6 0.59

ระยะเวลาในการตดิตามต ัง้แตก่นัยายน 2002-Jan 2009

ความสมัพนัธข์องการไดร้บั INH เพือ่รกัษาการตดิเชือ้วณัโรคแฝง (TLTI) กบัการเกดิวณัโรคในผูต้ดิเชือ้เอชไอว ี( PLHIV cohort study in 8 hospitals by RIT)

TB case/N

ODD Ratio95 %

confidence interval

P value

ไมไ่ดร้บัยา INH 164/1483 4.28 2.29-8.83

0.001

ไดร้บัยา INH กอ่นและหลงัเขา้โครงการ

11/379 1 - -

(PLHIV ทีไ่มไ่ดร้บัยา INH มโีอกาสป่วยเป็นวณัโรคมากกวา่คนทีไ่ดร้บั 4.28 เทา่ อยา่งมนียัส าคญัทางสถติ ิ

ระยะเวลาในการตดิตามต ัง้แตก่นัยายน 2002-Jan 2009

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IPT Implementation progress

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Barriers to and Motivations for the Implementation of a TreatmentProgramme for Latent Tuberculosis Infection using Isoniazid for

People Living with HIV, in Upper Northern ThailandSaiyud Moolphate1,2, Saranath Lawpoolsri1, Petchawan Pungrassami3,4, Natpatou Sanguanwongse5, Norio

Yamada2 & Jaranit Kaewkungwal1

Global Journal of Health Science; Vol. 5, No. 4; 2013ISSN 1916-9736 E-ISSN 1916-9744Published by Canadian Center of Science and Education

Methods/ Results

• Self-administered questionaires to HCW in 95 public hospitals in upper north Thailand

• Response rate from hospital 94%

• From HCW’s 70%

• IPT programme was implemented 18/89

(20%)

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By 144 HCWs in hospitals without IPT programme

1. Unclear direction of national policy(60%)

2. Fear of emerging INH resistant TB (52%)

3. Fear of poor adherence (30%)

4. Difficulty with the admin of TST (24%)

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Barrriers

5. Workload (19%)

6. Fear of toxicity of INH (18%)

7. Most HIV+ already got ART (17%)

8. Unsure about the effectiveness of IPT (17%)

9. IPT has short term benefit (12%)

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Barrriers

From 38 HCWs in hospitals implemented

1. Knowledge that IPT can prevent TB (63%)

2. Following national guideline (34%)

3. Concern for TB prevention even after the expansion of access to ART (32%)

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Motivations

• Communicable Disease Control Region 10, Chiangmai

• RIT Japan

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Acknowledgements

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Thank you for your kind attention