TUBERCULOSIS, TB/HIV & MDR-TB The Perfect Storm: TUBERCULOSIS, TB/HIV & MDR-TB Dr Mario Raviglione Director, Stop TB Department WHO Geneva Reversing the Tide: the End of Tuberculosis Columbia University, New York, March 2006

TB control crucial within development agendas Why talk of TB? TB control crucial within development agendas disease of poverty – by definition TB control is: a human right, a public good, an MDG quick-win ignorance is a killer

The burden of TB in 2006 1.7 million deaths in 2004 – 98% of these in developing world 250,000 deaths due to TB/HIV MDR-TB present in 102 of 109 countries 8.9 million new cases in 2004 – 80% in 22 high-burden countries

Highest incidence rates per capita in Africa… = 300 or more The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2005. All rights reserved

…but 2/3 of global cases in Asia = 1 million or more

Impact of HIV on TB and of TB in PLWHA Direct: Reactivation of TB infection acquired before HIV infection (from 10% lifetime to 3-13%/year) Rapid progression of TB infection acquired after HIV infection (often a matter of weeks, not months/years) Rapid progression of HIV disease (result of a more immunocompromised status) TB leading cause of HIV-related deaths in the world Indirect: TB transmission to the rest of the population, regardless of the HIV status

TB and TB/HIV in Africa The facts: 2.35m estimated cases per year in Sub Saharan Africa About 50% of them detected 29% of global total, yet only 11% or world's population ½m TB deaths annually, half of them associated with HIV TB notification rates falling in HIV uninfected people while high in HIV infected

MDR-TB prevalence in new cases, 1994-2003 14.2 Kazakhstan 14.2 Israel 13.7 Russia (Tomsk) 13.2 Uzbekistan 7.8 12.2 Estonia 10.4 China (Liaoning) 9.4 Lithuania 9.3 Latvia 9.0 Russia (Ivanovo) 7.8 China (Henan) 6.6 Dominican Rep 5.3 Ivory Coast 5.0 Iran 4.9 Ecuador

Economic impact of TB ALSO: Provision of diagnostic and treatment services: US$ 4.7 billion per year on average required as outlined in the Global Plan Productivity losses due to mortality: 1.7 million deaths per year, mainly economically productive adults Macro-economic level: recent study suggests 10% increase in TB incidence cuts economic growth by 0.2% - 0.4% per year Sources: Croft et al, 1998; Needham et al, 1998; Wyss et al, 2001; Rajeshwari et al, 1999; Floyd et al, 2003; Nganda et al, 2003; Wandwalo et al, 2005; Okello et al, 2003; Floyd et al, 1997; Khan et al, 2002

Cost per DALY gained in Asia and Africa Investment in TB control is highly-cost effective Intervention Cost per DALY gained in Asia and Africa Disease Control Priorities Project (year 2001 US$) BMJ series on MDGs (year 2000 US$) Treatment of new smear-positive cases, DOTS 5-33 2 Treatment of new smear-negative/ extrapulmonary cases, DOTS 63-116 ~10-20 Treatment of MDR-TB 75-130 ~30-50 ART for HIV+ people, including those with TB 103-175 ~120-250 In 2 regions with vast majority of global cases, main TB control interventions cost around or less than US$100 per year of life saved BMJ series on MDGs for health, rated all TB control interventions "highly cost-effective" (cost to gain 1 DALY less than GDP per capita) Sources: Dye and Floyd, 2006; Baltussen et al, BMJ 2005; Evans et al, 2005

Global TB control targets Stop TB Partnership – 2015: 50% reduction in TB prevalence and deaths by 2015 Millennium Development Goals – 2015, Goal 6: Combat HIV/AIDS, malaria and other diseases Target 8: to have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Indicator 23: prevalence and deaths associated with TB Indicator 24: proportion of TB cases detected and cured under DOTS World Health Assembly - 2005: - To detect at least 70% of infectious TB cases - To treat successfully at least 85% of detected cases

DOTS treatment success close to target for 1.7m smear (+) patients in 2003 WHA Target 85% Treatment success (%)

More than 22 million patients treated through DOTS in 10 years… and accelerating! 80 WHA target 70% 70 60 accelerated progress: target 2005 50 Case detection rate, smear-positive cases (%) 40 DOTS begins 30 average rate of progress 1995-2000 20 10 1990 1995 2000 2005 2010 2015 Year

Trends in global TB prevalence and deaths 290 32 280 31 270 30 260 29 TB prevalence rate (all forms)/100k TB death rate/100k/yr 250 28 240 27 230 26 220 25 2000 2001 2002 2003 2004

Global TB incidence is rising Estimated TB incidence/100K/yr Global incidence is rising at 1% Global TB incidence is rising 1% per year Africa - high HIV 400 300 Africa - low HIV 200 Estimated TB incidence/100K/yr World E Europe 100 World exc Afr EEur 1990 1995 2000 2005

WHO recommended Stop TB Strategy to reach the 2015 MDGs

G8 leaders commit to TB control in final communiqué Commitment to fight TB and TB/HIV in Africa May 2005 World Health Assembly resolution on sustainable financing for TB control July 2005 G8 leaders commit to TB control in final communiqué August 2005 46 Ministers of Health in Africa declare TB an emergency across the Region October 2005 African Union Ministers of Health support the TB emergency declaration in Africa

The Global Plan to Stop TB 2006-2015: Actions for Life "If 2005 was the year of commitment, then 2006 must be the year of delivery" Gordon Brown UK Finance Minister "We're willing to triple our funding for tuberculosis, and we urge others to do the same" Bill Gates, Microsoft founder "…call upon African governments to commit their share of the resources needed…" Olusegun Obasanjo, Nigerian President

Structure of the Global Plan to Stop TB 2006-2015 Part I "If 2005 was the year of commitment, then 2006 must be the year of delivery" Gordon Brown UK Finance Minister Part I General strategic directions Part II Regional scenarios Part III Specific actions/plans by area of work and secretariat "We're willing to triple our funding for tuberculosis, and we urge others to do the same" Bill Gates, Microsoft founder "…call upon African governments to commit their share of the resources needed…" Olusegun Obasanjo, Nigerian President

Global Plan to Stop TB 2006-2015 Total funding needs: available funding and funding gap by area of work

Global Plan key messages Funding the Global Plan will: treat 50 million TB patients save 14 million extra lives The ultimate goal of TB - elimination by 2050 - depends on continued innovation in vaccines, drugs and diagnostics Achievable and possible - under the $56 billion action plan for 10 years

A "perfect storm" but still off the radar? Combat HIV/AIDS, malaria and 'other diseases' African Minister of Health: "I thought TB was only a side effect of HIV/AIDS" Increase in annual international funding, 2000-2005: $5 billion for HIV/AIDS vs just $300 million for TB Only 15% of $9.5 billion to TB in first 5 rounds For Africa: Multicountry AIDS Programme, Malaria Booster Programme and just 3 TB projects PepFAR: minimum financing for TB/HIV

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