Pre-conference Meeting Report Sevim Ahmedov Sr TB Technical Adviser, USAID sahmedov@usaid.gov

Main Topics and Messages TB is the leading infectious disease killer of PLHIV Proven interventions to reduce TB mortality among PLHIV exist but require urgent scaling-up of implementation More resources are needed to address TB funding gaps The UN High-Level Meeting (UN HLM) on TB (September 2018) provides a unique opportunity to propel the TB and TB/HIV response Call to Action on TB/HIV!

Trends of Estimated TB and HIV deaths, 2000–2016 37% of the 1 million AIDS deaths in 2016 were due to TB Source: Global TB Report, 2017

Impressive scale-up of ART in People living with HIV 21.7 million PLHIV receiving ART by Dec 2017 59% of 36.9M PLHIV Source: UNAIDS/WHO estimate

ART is necessary, but not sufficient, to prevent TB TB risk remains high among HIV+ people on long-term ART Gupta PLoS ONE 2012;7:e34156

ART + TPT = better prevention Rangaka Lancet 2014;384:682 TEMPRANO NEJM 2015;373:808

Only 12/30 high TBHIV burden countries reported on IPT in 2016 Initiation of TB preventive treatment to People living with HIV, 2005-2016 Yet despite this progress has been limited. Graph shows countries reporting implementation of IPT in PLHIV up until 2016 worldwide. Only 60 countries reported in 2017 –including 12 of the 30 high burden countries. Source: Global Tuberculosis Report 2017 Only 12/30 high TBHIV burden countries reported on IPT in 2016

Gap in TB detection and TB preventive treatment for people who were newly enrolled in HIV care in high burden countries in 2016 71% 86% 83% 64% 83% 71% 64% 23% 48% 42% 21% This bar chart shows gaps in green of people newly enrolled in HIV care that have either not been detected with TB or who have not been initiated on TB preventive treatment. So among countries reporting TB prevention, the gap ranges from as high as 86% to 21%. Source: Global Tuberculosis Report 2017 Considerable gaps in coverage in reporting countries with high burden of TB and HIV-associated TB

Treatment options 3RH should be offered as an alternative to 6H for children and adolescents aged < 15 years. (New) 3HP treatment may be offered as an alternative to 6H for both adults and children in countries with a high TB incidence.(New)   Intervention Comparator N Active TB Mortality AEs Hepato-toxicity Completion rate Adults with HIV 3HP 6H or 9H 2 0.73 (0.23- 2.3) 0.75 (0.44 - 1.27) 0.63 (0.43 - 0.92) 0.26 (0.12 - 0.55) 1.25 (1.01-1.55) continuous INH 1 1.50 (0.69-3.27) 1.06 (0.47-2.41) 0.20 (0.12-0.32) 0.05 (0.02-0.13) 1.59 (1.40-1.80) Adults without HIV 9H 0.44 ( 0.18-1.07) (0.47-1.19) 0.87 (0.73-1.04) 0.16 (0.10- 0.27) 1.19 (1.16- 1.22) Children and adolescents 0.13 (0.01-2.54) 0.18 (0.01-3.80) 0.88 (0.32-2.40) - 1.09 (1.03-1.15)

Summary of Recent Advances TB preventive therapy SAVES LIVES for people with HIV (TEMPRANO and REALITY) 6 months of IPT has durable benefit, even in African settings ART is essential and has additional benefit 3HP is a promising option for HIV+ people 1HP could be transformational for global TB We can probably do even better Bedaquiline alone or in combination with rifapentine Injectable bedaquiline?

Chaisson and Golub, Lancet Global Health, 2017

TB Resource needs updated up to 2022 For Implementation During 2018-2022, 65 billion USD will be needed with an average annual need of 13 billion USD Current funding needs to doubled For Research and Development Annual funding is about 0.7 billion USD with a gap of 1.3 billion USD per annum Current funding needs to be tripled

How do we meet the resource needs for TB Increase domestic funding Increase external funding Other sources of funding: Innovative funding mechanisms, loans, bonds, insurance, private sector resources, etc. Smart investments and efficiency gains HIV budgets should fund TB-related care for PLHIV ART for co-infected TB case finding among PLHIV Preventive TB therapy for PLHIV

Concluding notes Dr. Pillay Strategies are clear: WHO and Stop TB Partnership We can get political commitment but we must use every opportunity to make the case for the end of TB as a public health threat We need to mobilise all politicians to ensure that TB gets the budget it needs at local and global levels Need to work closely with diplomats in NYC to get the best possible political declaration in September Engagement with the community and civil society is crucial Lets not ‘waste’ the opportunity presented by the HLM on TB!

Together we can prevent 2 million deaths by 2022 Key Asks from HIV/TB Stakeholders and Communities Transform the TB/HIV response to be more equitable, rights based and people centred Galvanize stakeholders at all levels, and ensure effective use of all available resources to address TB/HIV co-infection Reach all people living with TB/HIV co-infection by eliminating gaps and barriers in access to prevention, diagnosis and treatment Accelerate the development and implementation of new prevention, diagnostic and treatment tools and technologies to address TB/HIV co‑infection Commit to rigorous monitoring and evaluation of programs that are in place, and ensure that TB/HIV targets are included in country-level accountability frameworks