Diagnosis of HIV and TB in the Finnish primary health care. Pekka Suomalainen M.D

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1 Diagnosis of HIV and TB in the Finnish primary health care Inter-regional international conference Early diagnosis of HIV and associated infections, including TB, in the primary healthcare sector Petrozavodsk Pekka Suomalainen M.D Specialist in Internal Medicine and Infectious Diseases Special competence in Hospital Hygiene (Finnish Medical Association) Chief Physician, the Physician in charge of Communicable Diseases Dept. of Infectious Diseases and Hospital Hygiene South Karelia Health District,South Karelia Central Hospital Lappeenranta, FINLAND Member, Council for Communicable Diseases, Finnish Ministry of Social Affairs and Health Member, the Subcommittee for Renewal of Communicable Diseases Act 2018, Finnish Ministry of Social Affairs and Health Member, Council for Communicable Diseases, Regional State Administrative Agencies for Southern Finland

2 Primary health care services in Finland have been and are still mostly provided separately by municipal health services and specialized medical care in hospital districts Most Finnish health districts Eksote South Karelia Primary care Primary care Specialized health care in hospital districts Specialized health care

3 HIV-infection in Finland year 2016 New HIVdiagnosis HIV - Mode of transmission Total % Male Origin of birth not in Finland AIDS 183 patients 68% 60% 27 patients 20 diagnosed at the same time as HIV ( 11%) Heterosexual contact MSM (Men who have Sex with Men) IDU Mother to child Other 58% 32% 3% 1% 3% ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

4 Finland s HIV Strategy Prevent, Test, Treat National Institute for Health and Welfare (THL) The main objective of Finnish HIV work is to decrease the number of new HIV infections and the morbidity and mortality caused by infections as well as minimize the effects of HIV for those who are infected, the people who are close to those have been infected and on the level of society as a whole. Prevent Test Treat ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

5 Preventing HIV-infection Focusing on the key groups for HIV with customised services Groups where the incidence or occurrence of HIV is higher than in the general population Include some significant factor that exposes its members to the risk of being infected with HIV The key factors that will help achieve the goals of HIV work include removing the stigmas associated with these groups and the elimination of any discrimination The shame and lack of self-respect that stigma and discrimination cause increase risky behaviour and prevent people from seeking out the services that would help them

6 The key groups for preventive HIV work in Finland People who have been infected with HIV Gay and bi men as well as other men who have sex with men Intravenous drug users After the Finnish Helsinki-region epidemic at the turn of the millennium, infections related to intravenous drug use have remained at a very low level with the help of targeted health guidance and special services for HIV-positive drug users. Prisoners Sex workers Immigrants who are in a vulnerable position when it comes to HIV Travellers who have an increased risk of being infected with HIV Special care must be taken to ensure that young people are provided with wide-ranging sexual education ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

7 HIV IDU-USE INFECTED IN FINLAND (% of all HIV-infections)

8 Lappeenranta South Karelia Health District (population ) IDU Needle Exchange and Health Center The Finnish legislation Communicable Diseases Decree section 6 The municipal body responsible for the prevention of communicable diseases is responsible for health advice to intravenous drug users and exchange of injecting equipment as necessary for the prevention of communicable diseases Lappeenranta South Karelia Health District IDU Needle Exchange and Health Advice Center 2017 Customers/ patients / day (av.) Distributed new IDU needles and syringes / month (av.) 12,

9 Focus on more efficient testing for HIV in the primary care HIVAgAb-test Easy access to testing in the primary health care Patient derived Without medical assesment in every primary care center, even anonymously : I would like to have a HIV-test No stigma in testing Medically derived with a very low threshold HIV- testing must be a part of the normal health care Focused testing in the groups mentioned above (key groups for prevention) ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

10 More update and future solutions for even easier HIV-testing in Finland Free walk-in HIV-testing with NGO co operators MSM, Gay - clubs, IDU etc. Anonymous testing also in national primary health care Testing via Internet in primary health care Home HIV-tests should be available for purchase in Finnish pharmacies during year 2018 In collaboration with the National Institute for Health and Welfare ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

11 HIV? Other STD? Pilot testing HIV and other STD in South Karelia via Internet Eksote webpage Enrollment to Eksote internal web (e.g mobile securitycode or banking code) Request for communication LAB Information to the patient via safe communication electronically Questionnaire form Referral to lab (HIVagab, U-CtGcNhO, S-TrpaAb) Free condoms by post if desired Test results NEG POS Doctors appointment

12 HIV testing must be enchanced also in the aging population (Note: sex-travellers )

13 South Karelian native born male citizens having acquired their HIV-infection abroad Origin of infection (country) Number of HIVinfections Russia 17 Thailand 1 Estonia ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI 13

14 Landmark HIV-study (The PARTNER study) to further motivate the primary care to test for HIV Sexual activity without condoms and risk of HIV transmission in serodiscordant couples when the HIV-positive partner is using suppressive antiretroviral therapy. Rodger AJ et al for the PARTNER study group JAMA, 2016;316(2):1-11 Heterosexual and MSM couples having ongoing condomless sex over 1238 couple-years of follow-up - no cases of withincouple HIV transmission ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

15 The target of the Joint United Nations Programme on HIV and AIDS how does Finland cope? 90 % of all people living with HIV will know their HIV status The share of those who know their HIV status in Finland is estimated to be under 90 %, meaning that there is a need for more extensive testing. 90 % of all people with diagnosed HIV infection will receive sustained antiretroviral therapy Finland most likely > 90% but reliable evaluation requires the establishment of a national treatment register 90 % of all people receiving antiretroviral therapy will have viral suppression Finland: Most likely more than > 95% ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

16 Finnish National Tuberculosis Control Programme 2013 Finnish Ministry of Social Affairs and Health The National Tuberculosis Control Programme sets the following objectives: Identification of diseased persons as early as possible Efficient treatment Successful treatment in 80 per cent of those with infectious pulmonary tuberculosis Year 2015 in Finland 76% Efficient prevention of new infections Reducing the risk of contracting the disease Improved knowledge and skills of health care staff ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

17 The incidence of tuberculosis is at its lowest point since the beginning of the TB- registration in Finland. The primary care needs more and more training to even suspect tuberculosis TB cases, incidence / inhabitants ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

18 Epidemiology of tuberculosis in Finland- incidence ,00 4,50 6,00 4,00 3,50 5,00 4,00 Tuberculosis (all) Cases / inhabitants 3,00 2,50 Tuberculosis of the lung Cases / inhabitants 3,00 2, : 4,16 cases / inhabitants 2,00 1,50 1, : 2,98 cases / inhabitants 1,00 0,50 0, , ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI Statistics database of the National Infectious Diseases Register 18

19 HIV and tuberculosis co-infection in Finland Year 2016 out of 231 diagnosed TB-patients in Finland only five (2%) had concomitant HIVinfection

20 Focused tuberculosis diagnostics in Finland recommendation by The Finnish National Institute for Health and Welfare Immigrants / students from foreign countries Focused diagnostics if Country of birth or nationality in countries that have a very high incidence of TB WHO : > 150 TB-cases / inhabitants (country list ) Estimated stay in Finland > three months Migrants and asylum seekers Focused diagnostics if Country of birth or nationality in countries with high incidence of TB WHO : > 50 TB cases / inhabitants ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

21 Focused tuberculosis diagnostics in Finland - legislation (The Finnish Act for Communicable Disease) Health care /social welfare workers and those who care for children under (kindergarten workers) 7 yrs AND Are born in very high incidence countries Have lived for 12 months or worked in healthcare for 3 months in countries with very high incidence Have actively treated TB-patients Are close contacts to a TB patient Health care /social welfare workers who care for newborn children As above but a country with high incidence ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

22 New TB - diagnostic methods are being introduced even to the primary care Blood IGRA-tests PPD (Mantoux) B-TbIFNg-tests Russia? Skin based IGRA tests? GeneXpert PCR Rapid diagnosis with additionally prelinimary information about resistance (RMP) Even first line in sputum samples

23 Tuberculosis contact tracing. Updated guidelines in Finland. National Institute for Health and Welfare (THL) 2018.Primary health care is responsible for contact tracing in Finland Patient diagnosed with tuberculosis (INDEX patient) Tuberculosis of the lung (contact tracing necessary) Contacts: HIGH transmission risk Smear positive Smear negative but cavernous chest X-ray Contacts; LOW transmission risk Smear negative TB index patient < 16 yrs of age 16-35yrs of age? Age < 7 yrs > 8 hrs exposure Age > 7 yrs > 40 hrs exposure Members of the household Other close contacts Age < 7 yrs and > 40 hrs exposure in area < 60 m² Search for the TB-source! Members of the household Other inner circle Examining the patient Treating TB if found Evaluation the need for LTBI-treatment (Latent TB treatment) If found -> TB-treatment ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

24 Tuberculosis updated contact tracing guidelines in Finland (2018) Evaluating Latent Tuberculosis Infection (LTBI) and its treatment options Index TB - patient with a transmission risk Contact < 7 yrs of CC age Contact > 7 yrs of age with immunosuppression Contacts 7yrs- 35 yrs of age without immunosuppression Pediatric clinic within one week Special clinic Chest X-ray IGRA-testing (B-TbIFNg) Primary care Chest X-ray Questionnaire IGRA (B-TbIFNg) after 2 months since the last contact with index patient B-TbIFNg > 1.0 IU B-TbIFNg > 1.0 IU Evaluation for LTBI-treatment, INH 6 months or RMP+INH 3 months ETELÄ-KARJALAN SOSIAALI- JA TERVEYSPIIRI

25 Terveisiä Lappeenrannasta С приветом из Лаппеенранты Спасибо за внимание Thank you for your attention Kiitos mielenkiinnostanne