PRIORITIZING TB in 2018 PEPFAR COPS Erica Lessem Treatment Action Group January 2018 Erica.lessem@Treatmentactiongroup.org

TB/HIV Statistics People with HIV are 21 times more likely to develop TB There were 10.4 million new cases of TB worldwide in 2016, of which 1.03 million cases arose in people with HIV TB is the number one killer of people with HIV 23% of HIV deaths were due to TB disease However, with care, TB/HIV co-infection is manageable and allows for long, healthy lives Number of deaths worldwide in 2016, according to the 2017 WHO Global TB Report and 2017 UNAIDS Factsheet Concept courtesy of ACTION TB/HIV

TB/HIV Global Burden of Disease Countries with the highest burden of TB/HIV co-infection*: *The HBC list is defined as the top 20 countries in terms of absolute number of incident cases and the top 10 countries with the most severe burden in terms of incidence rates per capita not captured by the top 20 and meet a minimum threshold of the absolute number of incident cases (1,000 per year for TB/HIV). TB/HIV Source: http://apps.who.int/iris/bitstream/10665/259366/1/9789241565516-eng.pdf?ua=1

Integrating the TB/HIV response to improve care

COPS Priorities

Screening & diagnosis (1) TB and HIV testing is widely available, and free of charge, including: HIV testing offered to all patients diagnosed with TB TB testing using Xpert MTB/RIF Ultra offered to all patients diagnosed with HIV TB screening integrated into primary health care and ANC clinics for all newly diagnosed PLHIV, including with chest x-ray (digital) symptom screens at every visit TB-LAM testing for all presenting to health care with AIDS (advanced HIV or CD4<100 cells/mm3) or danger signs operational research to use at CD4<200 cells/mm3 Not so fun fact: <55% of PEPFAR supported PLHIV on ART (6.8ml out of the 12.6ml) were screened for TB in 2017 For more information on the Global Plan to End TB 2016-2020: http://www.stoptb.org/global/plan/plan2/ ADVOCACY

Screening & diagnosis (2) Ensure linkage to treatment Establish / strengthen specimen transport systems to improve access to lab services and efficient return of results Laboratory capacity strengthened, including full TB drug susceptibility testing i.e. liquid culture and first- and second-line line probe assays For more information on the Global Plan to End TB 2016-2020: http://www.stoptb.org/global/plan/plan2/ ADVOCACY

Prevention (1 of 2) TB preventive therapy for all PLHIV without active TB disease, and other prevention measures including: Immediate ART start for people with newly diagnosed HIV Temprano study (2015): starting ART immediately reduced risk of death and serious HIV related illnesses, including TB, by 44%. Preventive therapy offered and in regular supply using recommended regimens: 6 or 9 months of daily isoniazid + B6, now available with cotrimoxazole; 3 months of weekly isoniazid plus rifapentine, and B6; 3 or 4 months of daily isoniazid plus rifampicin, and B6; 3 or 4 months of daily rifampicin alone For more information on the Global Plan to End TB 2016-2020: http://www.stoptb.org/global/plan/plan2/ Source: Danel C, Gabillard D, Carrou JL, et al. Early ART and IPT in HIV-infected African adults with high CD4 count (Temprano trial). Paper presented at: 22nd Conference on Retroviruses and Opportunistic Infections; 2015 February 23–26; Seattle, WA.

Prevention (2 of 2) Infection control, including properly designed facilities, N95 respirators for healthcare workers, and information for patients and caregivers about preventing the spread of TB Contact tracing and active case finding Routine screening for all, especially high-risk populations (e.g. children, prisoners, miners, women presenting to antenatal clinics, etc.) Not so fun fact: Out of 5M who screened negative for TB in 2017, only 637,000 (~13%) started TB preventive therapy For more information on the Global Plan to End TB 2016-2020: http://www.stoptb.org/global/plan/plan2/ ADVOCACY

Treatment (1 of 2) Timely and free treatment for all people with TB diagnosed with HIV, and all people with HIV diagnosed with TB, with medicines in regular supply, including: Early universal ART for all people with TB diagnosed with HIV People with CD4 counts <50 cells/mm3 should start ART after 2 weeks people with CD4 >50 cells/mm3 or people with TB meningitis should start ART after 8-12 weeks This is to avoid IRIS, which is still unfortunately common in TB/HIV co-infected people TB treatment for all people with HIV with TB (confirmed or in need of empirical treatment) based on drug susceptibility results using daily fixed-dose combinations for adults and children with drug-sensitive TB For more information on the Global Plan to End TB 2016-2020: http://www.stoptb.org/global/plan/plan2/ ADVOCACY

Treatment (2 of 2) Person-centered care delivery in an environment conducive to patient needs and treatment success including: counseling for both HIV and TB integrated TB/HIV care delivery accessible clinic hours and/or community-based care access to transportation support Management of drug-drug interactions, including through dose adjustments (and potentially rifabutin as necessary) Medicines and supplements to support treatment nutritional support for those who need it anti-emetics, anti-pain medicines, and vitamin B6 (pyridoxine) Side effect risk assessment and monitoring at baseline and regularly once on treatment Task shifting to community health workers Integrated supply chain management for TB and HIV supplies For more information on the Global Plan to End TB 2016-2020: http://www.stoptb.org/global/plan/plan2/

INTEGRATIVE TOOLS Diagnostics that can work on both HIV and TB, or work well in people with TB/HIV, can help forge integration: GeneXpert contains a cartridge for detection of TB (MTB/RIF Ultra) and a cartridge for detection of HIV viral load and early infant diagnosis, as well as other diagnostic cartridges Centralized high throughput assays can be used to test for TB drug susceptibility as well as viral loading testing, such assays include Abbott’s Real Time Platform LAM test is a point-of-care diagnostic tool, which is able to test for TB in people living with HIV who have CD4 levels <100 cells/m3 or who are very sick Preventive therapy, recommended in all people with HIV without TB, also offers a path for integration: e.g. fixed dose formulation of isoniazid/co-trimoxazole/B6 For other regimens see slide 8 INTEGRATION

With thanks to Sevim Ahmedov, Bill Coggin, Mark Harrington for sharing their technical expertise (views here are my own, not theirs) Thanks to the TAG TB team for their development of an earlier iteration of this checklist