Considerations in Alternative Therapy

1

The Role of the Provider in the Elimination of
HIV, Tuberculosis, and Syphilis
Michael P. Johnson, MD, MPH
MP Johnson, MD, MPH, June 2001
2
Prevention/Elimination PlansHIV, Tuberculosis,
Syphilis

• No Time to Lose Getting More from HIV Prevention
  (2000)
• IOM Study, found at www.nap.edu/books/0309071372/
  html/
• Ending Neglect The Elimination of Tuberculosis
  in the US (2000)
• IOM Study, found at www.nap.edu/catalog/9837.html
  
• Hidden Epidemic Confronting Sexually Transmitted
  Diseases (1997)
• IOM Study, found at www.nap.edu/catalog/5284.html
  
• National Plan to Eliminate Syphilis from the
  United States (1999)
• CDC Plan, found at www.cdc.gov/stopsyphilis/

3
HIV Prevention in Clinical Setting

• 44 MDs, with of patient population HIV 53
• Reported revisiting HIV prevention for one of
  following
• medical cue (such as STI) 44
• patient report of change in relationship 36
• doubt about patient report of behavior 12
• routinely conduct risk behavior discussion 12

Adapted from Gerbert, AIDS Educ Prev, 1999
4
HIV Prevention

• Risk Screening
• History sexual and drug using behavior
• underlying determinants of risky
  behavior
• Exam initial visit - syphilis, hepatitis,
  herpes simplex, consider culture for
  chlamydia/GC
• routine follow-up with some tests,
  which tests and how frequently not clear

5
HIV Prevention

• Behavioral Intervention
• Make targeted assessment (screening)
• Deliver targeted prevention messages
• Be prepared for referrals, especially for
  underlying barriers to prevention (e.g. violence,
  mental illness)
• Reinforce messages elsewhere in clinic/clinic
  staff

6
HIV Prevention

• Partner Notification
• Voluntary referral of partners/contacts for
  screening and care
• Ask about new contacts at each visit
• Partner notification can be done through health
  department or clinic resources/staff or local
  support/case management services

7
Reported TB CasesUnited States, 1979-1999
30000
28000
26000
Cases
24000
22000
20000
18000
Year
Adapted from CDC surveillance data
8
Number of TB Cases inUS-born vs. Foreign-born
Persons United States, 1992-1999
No. of Cases
Adapted from CDC surveillance data
9
Tuberculosis in RWCATitle III program

• Clients served in 1999 108,945
• Active tuberculosis
• active TB during the year 689 (0.6)
• newly dxed during the year 320 (46)
• Treatment of latent tuberculosis infection
• clinically indicated treatment 1,753 (1.6)

10
Administering the Tuberculin Skin Test

• Inject intradermally 0.1 ml
• of 5 TU PPD tuberculin
• Produce wheal 6 mm to
• 10 mm in diameter
• Read only induration
• 48-72 hrs after placement
• Reaction of 5 mm or greater in HIV-infected
• persons is a positive test

11
Treatment of Latent Tuberculosis Infection

• Isoniazid
• 9-month regimen considered optimal, can be given
  twice- weekly if directly observed
• Rifamycin / Pyrazinamide
• A rifamycin and PZA daily for 2 months
• Administration of rifampin (RIF) contraindicated
  with
• some protease inhibitors (PIs) and nonnucleoside
  
• reverse transcriptase inhibitors (NNRTIs)
• Rifabutin can be substituted, but requires dosage
  adjustments

Adapted from MMWR 2000 49 (No. RR-6)
12
Treatment of Tuberculosis for HIV-Positive
Persons

• Initial rx phase should consist of INH, RIF, PZA,
  EMB

• RIF-based regimens generally used for patients
• 1) who have not started antiretroviral therapy
• 2) for whom PIs or NNRTIs are not being used

• Rifabutin (RBN) may be substituted for rifampin
  (RIF)(with dose adjustment)
• Alternative regimen can be INH, EMB, PZA, SM

Adapted from Am J Respir Crit Care Med 1994 149
13
Ending Neglect Elimination of Tuberculosis in
the United States

• Target for elimination
• Less than 0.1 case per 100,000
• Recommendations
• Maintaining control - rx of active disease
• Speeding the decline - rx of latent infection
• Developing new tools - vaccine, diagnostics,
  drugs
• Engaging in global tb control - collaboration
• Mobilizing support for elimination - education,
  eval.

Adapted from Ending The Neglect, IOM, 2000
14
Primary and Secondary Syphilis - Reported Rates
for 15-19 Year old Females by Race and Ethnicity
United States, 1981-1998
Adapted from CDC surveillance data
Note Black, White, and Other are non-Hispanic.
15
Primary and Secondary Syphilis - Reported Rates
for 15-19 Year old Males by Race and Ethnicity
United States, 1981-1998
Adapted from CDC surveillance data
Note Black, White, and Other are non-Hispanic.
16
Diagnosis of Syphilis

• Darkfield microscopy is definitive
• Serologic (treponemal and non-treponemal) tests
  are presumptive
• Titers determine cure, failure,
  reinfection/relapse
• After therapy
• Cure 4-fold (or 2 dilution) decrease (e.g. from
  132 to 18)
• Failure no change or increase
• Reinfection documented titer response then a
  4-fold increase

Adapted from MMWR 199847RR-1
17
Therapy for Syphilis

• Parenteral penicillin G (Pen) is drug of choice
  for all stages of syphilis
• Doxycycline, 100mg PO BID x 2 wks, for
  pen-allergic
• Pen is the ONLY therapy with documented efficacy
  for neurosyphilis or for syphilis during
  pregnancy
• Primary/secondary syphilis 2.4 million units IM
• Follow-up 3, 6, 9, 12, 24 months
• Treatment failure within 6-12 months CSF exam
• Retreat with 7.2 million units of pen if normal
  CSF

Adapted from MMWR 199847RR-1
18
National Syphilis Elimination Plan

• Target for elimination
• reduce syphilis cases to 1,000 or fewer and
  increase the number of syphilis-free counties to
  90 by 2005 (national definition)
• absence of new cases within jurisdiction except
  within 90 days of report of imported case, (local
  definition)
• Recommendations
• Enhanced surveillance
• Strengthened community involvement and
  partnership
• Rapid outbreak response teams
• Expanded clinical and laboratory services
• Enhanced health promotion

Adapted from www.cdc.gov/stopsyphilis