TB/HIV surveillance : Who is going to get the job done? Reuben Granich, MD, MPH Medical Epidemiologist International Research and Programs Branch Division of Tuberculosis Elimination, National Center for HIV/AIDS, STD and Tuberculosis Prevention Centers for Disease Control and Prevention TB/HIV Surveillance Meeting, Atlanta, June 27-28, 2004

This talk will briefly discuss…. TB/HIV collaborative activities WHO-Revised National TB Control Program (RNTCP) medical consultants for rapid DOTS scale-up

DOTS Related Activities Ensure access to DOTS for all TB patients Expand and maintain program Assure drug supply Train and re-train staff Conduct monitoring and evaluation--field supervision, district reviews, etc. Use surveillance to meet NTP targets (e.g., 85% cure, 70% case detection) Build and support laboratory network “Other” activities Develop and implement IEC strategy/plan Conduct operational research (e.g., drug resistance surveys, prevalence surveys, etc.) Establish program for chronic patients Private public mix projects/program Review/revise NTP policy Respond to MoH requests for information Prepare funding proposals (e.g., GFATM, FIDELIS, World Bank, etc.) Attend meetings and EVERYTHING ELSE….

TB/HIV Collaborative Activities Establish mechanisms for collaboration Set up a coordinating body for TB/HIV activities Conduct surveillance of HIV prevalence among tuberculosis patients Carry out joint TB/HIV planning Conduct monitoring and evaluation Decrease the burden of tuberculosis in people living with HIV/AIDS Establish intensified tuberculosis case-finding Introduce isoniazid preventive therapy (IPT) Ensure tuberculosis infection control in health care and congregate settings Decrease the burden of HIV/AIDS in tuberculosis patients Provide HIV testing and counselling (VCT) Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy (CPT) Ensure HIV/AIDS care and support Introduce antiretroviral therapy WHO Interim Policy on Collaborative TB/HIV Activities

Thousands of patients waiting for care….

Challenges Health Sector Reform Hiring freezes and reduction of national level staffing Lack of funding for positions Poor infrastructure Lack of space for additional staff Bureaucratic delay in filling sanctioned posts Lack of qualified candidates domestic and international “Brain drain”

Emergency task force approach to DOTS expansion in India….

India WHO-RNTCP consultant network ~90 consultants 5 TB-HIV and 11 private-public mix 10-15 million population per consultant 5 consultants assisting NTP and AIDS program at national level Recruitment through professional agency followed by interview with a WHO-RNTCP panel Trained by WHO in collaboration with National TB Institutions Provided with transport, laptop computer and reimbursement of mobile telephone bills

National consultants meeting Lucknow, India February 2003

Role in expanding DOTS Role in improving DOTS

Role of TB-HIV consultants Facilitate collaboration between the two programmes Assist NTP & HIV/AIDS Programme in drafting documents joint action plans guidelines training material Facilitate training of HIV/AIDS and TB program staff Assist states in improving TB-HIV collaborative activities

Impact of Consultants 50% faster expansion* the median of 18 months to start service delivery in districts reduced to 9 months >10,000 additional cases treated under DOTS strategy per consultant, leading to nearly 2000 lives saved Treatment success rate increased from 78% to 83%* ~1000 additional patients successfully treated per consultant each year * Frieden and Khatri, Int J Tuberc Lung Dis, 2003; 7(9):837-841

Population in India covered under DOTS and total tuberculosis patients put on treatment each quarter, 1994-2003 4th Quarter: 237,256 Yearly total population projected from 2001 census.

Impact of Consultants (contd..)

Conclusion Consultant network for TB remarkably accelerated DOTS expansion in India Consultants significantly contribute towards India achieving the WHO target for treatment success Consultants increase case detection through facilitation of private public mix projects and involvement of medical colleges Success of the consultant network in India may provide a model for scale-up of HIV/AIDS care activities

Acknowledgements LS Chauhan S Khatri T Frieden A Choudhary S Kumar S Bhambri R Garg D Roy P Shetty A Pathni S Sahu F Wares L Nelson C Wells USAID CIDA DFID WHO DTBE

Thanks! TB patient taking DOT, Maharashtra, India