CREATE’s Legacy
Early Friday morning, a symposium reviewed the accomplishments of the Consortium to Respond Effectively to the AIDS/TB Epidemic (CREATE) — which was established to conduct research to explore ways to reduce TB in areas with a high burden of HIV. The studies devised by CREATE enrolled over 1 million individuals, and contributed to the evidence-base for TB case finding — particularly household contact tracing interventions and the use of isoniazid preventive therapy to treat latent TB. Dr Haileyesus Getahun of WHO’s Global TB Programme said that the CREATE research helped move the field forward and contributed to policy development. But despite these advances and the development of new tools, many questions and clinical challenges remain. “There’s been encouraging progress but more and difficult questions need answered. We need more research and more investment.” 
Professor Peter Godfrey-Faussett of the London School of Hygiene and Tropical Medicine noted that CREATE helped develop infrastructure for research in the countries where it worked, and many of the sites continue and are now engaged in other studies, such as:
- PopART, the largest ongoing study of HIV prevention,
- the XTEND and XPHACTOR studies (refining the use of GeneXpert),
- INHIBIT TB — a study evaluating home-based TB, HIV and CD4 cell testing and home-based IPT and linkage to care is a modification of the ZAMSTAR study’s approach.
- TB Reach Wave 3 in mines focusing on screening mining communites based on experience working with the mines, and
- The Aurum TB Reach project, which uses a combination of ZAMSTAR and DETECT TB approaches.
Professor Godfrey-Faussett noted that some of the conclusions of CREATE’s were unanticipated. “All models are wrong, but some are useful,” he said. “The real world is messy and complex. But I still believe that large-scale interventional designs provide evidence about impact in the real world. I believe CREATE’s findings emphasise the need to work closely with households, communities and their health systems, as well as policy and advocacy stakeholders.”
Are we winning the fight against HIV?
During Friday’s plenary session, Professor Diane Havlir of UCSF reviewed some of the advances in the fight against HIV. Programmes have taken on board collaborative TB-HIV activities so that the two diseases are increasingly being co-managed in coinfected patients.
HIV is now a chronic disease with people li
ving longer on antiretroviral treatment. The contribution of HIV-related inflammation to morbidity and mortality experienced by people living with HIV as they age is becoming clearer and consequently leading to earlier treatment with better drugs.
“Despite challenges, there is movement to test global antiretroviral treatment in generalised epidemic,” she said. “We cannot wait until we have addressed all ‘late’ treatment issues before we focus on early treatment.” With this progress, new goals have come into sight — such as the UNAIDS ‘Getting to Zero policy in 2012. Engaging community advocacy for support in obtaining funding and reaching these goals has been critical according to Professor Havlir — which could serve as a lesson for the TB world.
With recent reports of at least two or more people living with HIV experiencing a functional cure, one might ask: ‘Are we winning the battle against HIV?
“We are neither winning or losing,” said Professor Havlir, “but we are in the fight of our lives. Winning the battle requires that we accelerate current efforts to end the epidemic, including massive HIV testing campaigns, combination prevention including antiretroviral treatment, stronger treatment cascade inclusive of most at risk populations, and further research. Success will reduce the burden of TB, strengthen maternal child health and pave the way to the chronic disease models of the future.”
Hand in hand screening for TB and HIV
Dr Shobna Sawry reported that repeated routine intensified TB case finding had a low yield in a cohort of HIV-infected children on ART in Johannesburg, South Africa. The children, aged from 0-8 years, were enrolled in a prospective cohort study (the THINK study) investigating the incidence of TB and BCG IRIS in children living with HIV starting ART at the clinic. First, children were screened for TB by routine clinic staff using standard of care procedures, and those not diagnosed with TB were subsequently re-screened on the day of starting ART, and their clinic visits thereafter. 1357 TB screens were performed in 221 children while not receiving TB treatment, yielding 71 (5.2%) positive TB screens in 55 children. Only 5 (9%) however, were started on TB treatment on the basis of X-rays, culture or clinical presentation.
It should be noted that half the children presented to the site were already on TB treatment at the time of initiating ART — and were thus excluded from the study — which may explain the low prevalence of TB symptoms at baseline. In the remainder, however, Dr Sawry suggested that the low incidence of positive TB screens could be due to the protective effect of ART-related immune reconstitution.
Dr E Soares presented data from Brazil showing that the uptake of tuberculin skin testing (TST) was improved significantly over what had been reported in CREATE’s THRio study, from 33 to 86% by including a TB skilled nurse with specific TB-related duties in HIV clinics. This also led to a decreased time to initiating IPT (from a median of 3 weeks down to one week). Dr Soares said further analyses were needed to see whether it was cost effective. “It is important to compare the costs of this model, which targeted those who really benefit from IPT (those who are TST+) to the cost effectiveness of providing universal IPT,” she said. Still to come:
- MSF’s experiences with the Gene Xpert MTB/Rif TB diagnosis assay in different epidemic settings
- The Church of Scotland Hospital in Tugela Ferry (the site of the infamous XDR-TB outbreak) demonstrates “effective reduction of nosocomial transmission of drug-resistant TB can be achieved by providing an integrated multipronged strategy and by establishing effective person centred and systems approach even in heavily impacted low resource settings,” according to Dr Tony Moll.
- Other reports on the implementation of infection control in Zambia and Botswana, as well as tools for engaging nursing associations and civil society for TB infection control implementation and the…
- Highlights from TAG/MSF’s Cascades: Improving TB Care Symposium