Diagnosis of HIV-Associated Tuberculosis
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1 Diagnosis of HIV-Associated Tuberculosis Stephen D. Lawn Desmond Tutu HIV Centre Institute of Infectious Disease and Molecular Medicine University of Cape Town Dept. Of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK NO CONFLICTS OF INTEREST TO DECLARE
2
3 Lawn & Zumla. Lancet 2011
4 OUTLINE 1. Defining the need 2. Revisiting the old 3. Ushering in the new 4. Looking to the future
5 TB notifications TB in Cape Town 2009 (n=29,478) HIV positive HIV unknown HIV negative Age strata Wood and Lawn PLoS ONE 2011
6 Lab Confirmation of TB Diagnoses vs Age 100% Smear + Smear - Culture + No Lab Confirmation 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 to 4 (n=2,853) 5 to 9 (n=722) 10 to 14 (n=393) 15 to 19 (n=1,436) 20 to 24 (n=3,184) 25 to 29 (n=4,294) 30 to 34 (n=4,284) 35 to 39 (n=3,762) 40 to 44 (n=2,840) 45 to 49 (n=2,245) 50 to 54 (n=1,479) 55 (n=1,986) Age (years)
7 Prevalence of LTBI by Age Wood / Lawn IJTLD 2010
8 TB / LTBI Spectrum Young et al. Trends Microbiol 2009 Lawn et al Clin Devel Immunol 2011
9 TB Notifications CD4 Count Distribution of Cases of HIV+ TB 2,000 PTB PTB + EPTB EPTB 1,500 1, CD4 count (cells/µl)
10 Mortality rate HIV-Associated TB Mortality Rate Africa Americas E. Mediterranean European S.E.Asian W. Pacific WHO Region Lawn et al. IJTLD 2009
11 TB Notifications TB notifications So What Do We Need? HIV positive HIV unknown HIV negative ,000 1,500 1, Age strata PTB PTB + EPTB EPTB CD4 count (cells/µl) Rapid detection of resistance to 1st and 2 nd line drugs Monitoring response to TB Rx Point-of-care! Low-cost Simple and feasible
12 OUTLINE 1. Defining the need 2. Revisiting the old 3. Ushering in the new 4. Looking to the future
13 Percentage of Notifications HIV Status, CD4 Count and PTB vs EPTB 100% PTB PTB + EPTB EPTB 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% <50 (n=2,123) (n=1,965) (n=1,721) (n=1,426) CD4 count (n=2,535) (n=1,163) 500 (n=883) (n=12,507) HIV+ HIV-
14 Percentage of Notifications HIV Status, CD4 Cell Count and Sputum Smear-Positive Grade 100% 90% 80% % 60% 50% 40% 30% 20% 10% 0% <50 (n=586) (n=456) (n=425) (n=377) (n=711) (n=405) >500 (n=269) (n=5,634) CD4 (cells / µl) HIV+ HIV-
15 Smear Positivity HIV Status, CD4 Count and Smear Status 80% 70% 60% 50% 40% 30% 20% 10% 0% <50 (n=1,530) (n=1,409) (n=1,255) (n=1,076) (n=1,896) (n=882) 500 (n=629) (n=9127) CD4 Count HIV+ HIV-
16 Increasing diagnostic sensitivity of in the very lowest CD4 cell count strata: Sputum Xpert MTB/RIF Urine LAM Urine Xpert MTB/RIF Lawn et al. Clin Infect Dis 2012 Lawn et al. JAIDS 2012
17 TB Notifications CD4 Count Distribution of Cases of HIV+ TB 2,000 PTB PTB + EPTB EPTB 1,500 1, CD4 count (cells/µl)
18 OUTLINE 1. Defining the need 2. Revisiting the old 3. Ushering in the new Symptom screening Diagnostic assays 4. Looking to the future
19
20 Symptom Screening Screen for presence of 1 of the following symptoms: 1. Current cough Sensitivity: 78.9% 2. Fever Specificity: 49.6% 3. Night sweats NPV: high if TB 4. Weight loss prevalence <10%
21 Proportion of TB diagnoses (%) Sensitivity of Symptom Screening for TB Pre-ART Induced sputum #2 Induced sputum #1 Spot sputum # WHO screen Any cough Cough >2 weeks All patients Patients with symptoms Lawn et al IJTLD 2012; in press
22 Culture Rapid molecular assays Antigen detection Electronic noses / breathalysers Biomarkers
23 Culture Automated liquid culture and phenotypic DST: gold standard Microcolony culture techniques: MODS / Thin Layer Agar Interim low-cost solution MODS commercialization Minion et al. Lancet Infect Dis 2010 Leung et al. IJTLD 2012 Feasibility / scale / impact?
24 Rapid Molecular Diagnostic Assays For TB Diagnosis and DST Line-Probe Assays WHO-approved in 2008 Eg Hain Lifesciences MTBDRplus Culture isolates: YES Smear-positive sputum: YES Smear-negative sputum: NO Technical complexity New GenoQuick MTB (Moure et al J Clin Micro 2012)
25 XPERT MTB/RIF
26
27 Xpert MTB/RIF: real-time PCR using thermocycling and molecular beacon technology Lawn & Nicol. Future Microbiology 2011
28 Sensitivity (%) Sensitivity of Xpert MTB/RIF Assay (FIND Multi-Country Evaluation) No. sputum samples tested Smear-positive Smear-negative Boehme et al NEJM 2010
29 December 2010 Type of TB Sensitivity Sputum smear-positive % Sputum smear-negative 57-83% Extrapulmonary (range of clinical samples) 25-95% Lawn & Nicol, Future Microbiology 2011 Lawn & Zumla, Exp Rev Anti-Infect Ther 2012
30 Xpert and EPTB Lawn & Zumla, Exp Rev Anti-Infect Ther 2012
31 Sensitivity (%) < >150 All patients CD4 cell count strata JAIDS 2012
32 Percentage (%) 45% increase in case detection Sensitivity Specificity Microscopy Xpert
33 Detection of Rifampicin Resistance Problem of false +ves New G4 cartridges launched Dec 2011
34 Xpert MTB/RIF: A game-changer? Pros include Exceptional performance for TB diagnosis Rapid RIF Resistance screening Near patient technology Some cons RIF resistance specificity Xpert-negative TB Expense 4 bay machine $17,000 1 cartridge approx $15 Simple but not simple enough Will it be used at point-of-care?
35 AIDS 2012
36 Xpert-negative TB patients had: very early TB disease less advanced HIV good prognosis Lawn et al Clin Infect Dis 2012
37 Impact of Xpert in South Africa?
38 Alive and inprogramme 90-day ART Programme Outcomes Xpert-NEG (n=25) Xpert-POS (n=64) P value 21 (84.0) 54 (84.4) 1.0 Dead 0 6 (9.4) <0.179 LTFU 4 (16.0) 8 (12.5) Transfer-out 0 1 (1.6) 1.0 Started TB Rx 17 (68) 49 (76.6) 0.4 Time to TB treatment (median [IQR] days) 32 (26-48) 9 (6-18) <0.001 Lawn et al Clin Infect Dis 2012
39 Lawn et al IJTLD 2012
40 Living with HIV, dying of TB We need a POC TB test!
41 Urine Antigen Detection Lipoarabinomannan (LAM)
42 Sensitivty Sensitivity of LAM ELISA for TB Screening Pre-ART CD4 >100 CD CD4 <50 Specificity 100% Microscopy LAM ELISA LAM ELISA + Microscopy Lawn et al. AIDS Shah et al JAIDS 2009
43 Determine TB-LAM Ag Control band Patient sample result Sample pad
44 Determine TB-LAM Ag Negative Interm. positive Strong positive
45 Lancet Infectious Diseases 2012
46 Agreement between two readers? Kappa= 0.97 (95%CI, ) Overall agreement 514/ % (95% CI )
47 Agreement between TB-ELISA and Determine TB-LAM Strips? Overall agreement 507/ % (95%CI, ) Kappa= 0.84 (95%CI, )
48 Diagnostiic sensitivity (%) Sensitivity of LAM POC test CD4 >150 CD4 = CD4 <50 Specificity >98% all strata 0 Smear LAM Smear + LAM Xpert Xpert +
49 Sensitivity of TB diagnostics among patients with a CD4 <100 cells/µl Liquid Culture Liquid Culture 100% Determine TB-LAM 52% z AFB + LAM = 66% Xpert MTB/RIF 76% Sputum AFB 35%
50 CD4 count Median (IQR) Hb Median (IQR) Sputum smearpositive (%) Days to culture positivity LAM-Negative (n=36) LAM-Positive (n=23) P value 115 (69-160) 37 ( ) ( ) 8.0 ( ) < (27.2) 10 (43.5) (14-24) 12 (9-17) Mortality (%) 0 5 (21.7) 0.007
51 Liquid culture AFB Sputum Microscopy Deaths Sputum Xpert MTB/RIF Determine TB-LAM
52 OUTLINE 1. Defining the need 2. Revisiting the old 3. Ushering in the new 4. Looking to the future
53 Culture Rapid molecular assays Antigen detection Electronic noses / breathalysers Biomarkers
54 LAMP: Loop Mediated Isothermal Amplification PCR is slow and requires thermocycling LAMP at stable elevated temperature Visual read-out Multiplexing not possible Second prototype: STAG 2012
55 Fast-Followers to Xpert:...Cheaper and Simpler Amplification at lower temps Low energy requirements Quick Smart-phone sized hardware Multiple drug resistance mutations...watch THIS SPACE!
56 Electronic Noses / Breathalyzers Electronic detection of volatile biomarkers using chemical sensors + pattern recognition system Rapid detection of Ag85B Kolk et al J Clin Micro 2010 McNerney et al BMC Infect Dis 2010
57 The Omics Era Transcriptomics Proteomics Metabolomics
58 Whole blood 393- transcript signature TB vs LTBI vs healthy controls TB before and after Rx Berry et al Nature 2010
59 CONCLUSIONS
60 CONCLUSIONS Huge progress over the past 5 years Major progress in rapid molecular techniques Xpert MTB/RIF is a huge step forward far from the prefect solution has triggered a huge amount of development Determine TB-LAM a POC niche for those with v. low CD4 counts Impact data needed
61 TB Notifications TB notifications So What Have We Got? HIV positive HIV unknown HIV negative ,000 1,500 1, Age strata PTB PTB + EPTB EPTB CD4 count (cells/µl) Rapid detection of resistance to 1st and 2 nd line drugs Monitoring response to TB Rx Point-of-care! Low-cost Simple and feasible
62 Acknowledgments Cape Town: Robin Wood, Linda-Gail Bekker, Andrew Kerkhoff, Sophie Brooks, Ankur Gupta, Rishi Gupta, Monica Vogt, Katharina Kranzer, Landon Myer, Matthew McNally, Pearl Pahlana + staff at Hannan Crusaid clinic Mark Nicol, Andrew Whitelaw + NHLS staff Harvard: Jason Andrews, Rochelle Walensky, Ken Freedberg FIND preferential pricing of cartridges Alere supplied LAM tests IIDMM, UCT, LSHTM, WT Bloomsbury Centre
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