The importance of TB and HIV programme collaboration and expanding the scope of collaboration for the future. 20 min. George Loth WHO/HIV/SRM

Learning without thinking is labour lost; thinking without learning is perilous Confucius VI BC

UNGASS Reduction of HIV prevalence by 25% in most affected countries Three million people in developing countries on HIV/AIDS treatment by 20005

Priorities ? Accelerating Access Initiative June 2002 Scaling Up ARV therapy in limited settings A commitment to Action for Expanded Access to HIV/AIDS treatment HIV December 2002

Increasing Access to HIV testing and counselling. From VCT to TC

Estimated Cost for T & C PMTCT : 46 million Treatment : 37 million Prevention : 101.1 million Grand total : 184.1 millionNew data

Analysis Inputs: Costs Per Client Cost Estimates: Health System Enhancements: $5 ($1-$9) Pretest Counseling: $2 ($1-$3) HIV Testing & Posttest Counseling –$6 ($3-$9) NVP –for mother and infant - $4.82 (+/- 25%) HIV Treatment for infants - $281($0-$562) Note – cost estimates may be conservative (lower than actual). Opted for lower cost estimates until better data is available.

Distribution of Cost Components

Inputs: Proportion of Prenatal Women who have at Least 1 ANC Visit

Inputs: Proportion of Women Receiving Pretest Counseling Data from UNICEF

Outcomes: % of HIV+ Mothers Reached and Treated with ARV

Target for ARV treatment 3 million on ART by 2005 by 2007, 45% requiring ART ,receive it (CMH). 40 million PWHAs in resource-limited setting 15% clinically sick enough to need ART Aspirational goal; without capacity development particularly human resources we will fail !

A Public Health approach Able to scale up ART to meet the needs of people living with HIV/AIDS in resource-limited settings standardisation and simplification of ARV regimes to support broad and efficient implementation, and accessible treatment programmes evidence-based recommendations aiming to avoid substandard or sub-optimal treatment or the creation of the potential for the emergence of drug resistant virus

When to start therapy

First line regimens

Second line regimens

Entry and Monitoring Must have: clinical assessment, HIV testing, and haemoglobin t Additional basic testing: white blood cell count and differential, LFTs, creatinine and/or blood urea nitrogen, serum glucose, and pregnancy tests for women. Desirable tests include bilirubin, amylase and serum lipids. CD4 cell determinations are very desirable and every effort should be made to make these widely available. Viral load testing is currently considered optional. Increasing recognition that access to laboratory monitoring will be a major access bottleneck

Underlying considerations Potent regimens (including at least 3 drugs) to prevent resistance and maximise benefit Standardisation to allow use in settings where HIV/AIDS specialists and tests to monitor treatment are not readily available and facilitate continuous availability of the drugs Recommendations on best available evidence Incorporate flexibility in regimens to manage toxicity Include specific groups - children, pregnancy, IDUs and co-pathology aim for standard first then second-line regimes

ART in HIV-positive patient with TB Not ideal to prescribe seven potentially toxic drugs together Many will be diagnosed with HIV when present with TB Recommend that TB patients complete TB therapy unless a high risk of HIV progression/death (CD4; dissemination) Try to complete induction treatment if possible without starting ARVs If clinically necessary treat both diseases together

ART in HIV-positive patient with TB CD4 below 50 and/or disseminated TB dual treatment indicated ZDV/3TC backbone; ABC or EFV or SQV/r preferred; CD4 between 50 - 200 or TLC < 1000-1200 complete 2 months of induction therapy same regime considerations Pulmonary TB and CD4 > 200 or TLC > 1000-1200 Treat TB Monitor clinical status; start ARV if necessary Start “standard” ART after therapy when indicated

ART in HIV-positive patients with TB Almost a data free-zone … need to review evidence and experience of first wave of TB-HIV treatment centres ASAP revise guidelines accordingly “In this rapidly evolving field, WHO recognises that these recommendations will need to be updated on a regular basis”

Conclusions Potentially huge additional TB-HIV disease burden which is currently ignored …... Unclear of extent and what to do If not addressed TB will continue as biggest killer in HIV (and we fail with UNGASS) TB is biggest opportunity for immediately improving outcome and survival for HIV-TB Go for a positive not fatalistic message

The further challenge Urgent need for collaboration ! Patient with unknown HIV and TB status and unknown patient Improvement of Surveillance (SGS and DHS+). Strengthening PHC / District HC on TB and HIV issues (undiagnosed). Support in high-burden countries acute medical services.

Not every thing that counts can be counted and everything that can be counted counts. Albert Einstein