WHO/AFRO Vision for TB/HIV Control. Presented at the 3rd Global TB/HIV Working Group Meeting. 4-6 June, 2003. By Dr Wilfred Nkhoma

Outline of presentation Magnitude of TB burden (including impact of dual TB/HIV infection) Performance with relation to targets AFRO’s Vision for combating TB/HIV What has been happening so far ? Where do we go from here ?

Total Reported Tuberculosis Cases, AFRO, 2000 Source: WHO/AFRO TB Program as of December 2001

Magnitude of the TB problem (1): Highest TB rates per capita are in Africa 25 to 49 50 to 99 100 to 299 < 10 10 to 24 300 or more No Estimate per 100 000 population 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 2002

Adults and children Living with HIV/AIDS. Estimates at the end of 2002 Continental Europe Oriental Europe & Central Asia North America 1,2 million Eastern & Pacific Asia 980 000 570 000 1,2 million North Africa & Maghreb region Caribbean South & South East Asia 440 000 550 000 6 millions Latin America Sub-Saharan African Australia & New Zealand 1,5million 29,4 millions 15 000 Total : 42 millions

S

HIV - MTB co-infection, 1999 co infected people (thousands) < 0.1 0.1 to 0.9 1 to 9 10 to 99 100 to 299 300 or more no estimate

In 1983, only one country, Tanzania was implementing what later became known as the DOTS Strategy. The number increased slowly at first until the early ninenties when TB control began to receive increased attention culminating in 1993 by the declaration of the the global emergency by WHO. Since then more and more countries have adopted the strategy and the rise was particularly exponential between 1994 and 1999. The number has remained static for two consecutive years since then, and little further movement is expected in the short term. For all intents and purposes, adoption of the strategy could be considered a prerequisite to effective TB Control. This trend in coverage is therefore a significant development for purposes of meeting global and regional targets for TB Control.

REPORTED DOTS COVERAGE BY COUNTRY. AFRO 2001

Case detection rates by WHO region 2001 100 80 60 40 20 AFR AMR EMR DOTS detection rate 60 Case detection (%) 40 20 AFR AMR EMR EUR SEAR WHO region

Treatment success rate by WHO Region : DOTS 1998 100 90 80 70 Not evaluated 60 Percent of cohort Not treated 50 successfully 40 30 Treated successfully 20 10 AFR AMR EMR EUR SEAR WPR

Compared to other WHO Regions, the picture is one of the most improved region between 1996 and 1998 cohorts, rivaled only by WPR and EUR. SEAR and EMR though higher than AFR, have witnessed a decline towards AFR levels.

TRENDS OF NEW HIV INFECTIONS IN AFRICA THE YEAR 2000 WAS THE FIRST TIME AFRICA SAW A DECREASE IN NEW INFECTIONS THE 3.8 MILLION NEW INFECTIONS IN 2000 WERE ACTUALLY LOWER THAN THE 4 MILLION NEW INFECTIONS OF 1999 3.4 NEW INFECTIONS IN 2001 WHY THE DROP ? EPIDEMIC HAS GONE ON FOR SO LONG THAT MOST PEOPLE AT RISK HAVE ALREADY BEEN INFECTED ? INTERVENTION PROGRAMMES BEGINNING TO PAY OFF ?

HIV Prevalence at Selected ANC Sentinel Sites UGANDA Source: HIV/AIDS Surveillance Report, June 2001, MoH

HIV prevalence rate among pregnant 15 to 19-year-olds, Lusaka, Zambia, 1993 to 1998 35 30 25 1993 HIV prevalence (%) 20 1994 1998 15 10 5 Chelstone Chilenje Kalingalinga Matero Clinic Source: Ministry of Health, Zambia, 1999

Median HIV Prevalence in ANC Attendees - Senegal Source: MoH, US Census Beureau

Estimated access to care interventions for HIV/AIDS in Africa South of the Sahara. 2001 6% access to VCT services 23% access to essential HIV/AIDS care package 6% coverage with Cotrimoxazole in adults and 1% in children Only 300,000 of 6 million people on ARVs are in developing countries Only 1% (50,000 of 4 million) of those in need of ARVs in developing countries have access to them. 1% coverage with PMTCT services

AFRO’s Vision for TB/HIV Control (1) Efficient delivery of core effective TB and HIV/AIDS prevention, care and support services: Universal application of DOTS strategy for TB and minimum package of services for HIV/AIDS

PRIORITY HIV/AIDS INTERVENTIONS (1) Prevention - Voluntary counselling & testing - Promotion of protective behaviours - Prevention & treatment of STIs - Adolescent health & development - Blood safety, bio-safety - Prevention of Mother-to-child transmission

PRIORITY HIV/AIDS INTERVENTIONS (2) Care & Support (within a continuum…) - Treatment of opportunistic infections, palliative care - Access to anti-retroviral drugs - Community-based care - VCT - TB/HIV programme & service links

PRIORITY HIV/AISDS INTERVENTIONS (3) Selection of essential package for different levels & service providers Based on community-defined needs & priorities, capacities, resources, opportunities Integrated into health service package

AFRO’s Vision for TB/HIV Control (2) Collaboration between TB & HIV/AIDS Control Programs aimed at: increased access to TB & HIV/AIDS prevention, care and support services as part of a continuum Reducing the incidence of HIV related tuberculosis Reducing morbidity and mortality due to TB and other Ois among PLWHA

Some key collaboration interventions between TB & HIV/AIDS/STD Control Programs Development of supportive policy environment Access to HIV VCT by TB patients Access to TB services for PLWHAs: Screening, diagnosis and treatment [expansion of DOTS], INH prophylaxis Prophylaxis for Ois: e.g Co-trimoxazole prophylaxis for PLWHA and TB patients Access to ARVs by HIV-positive TB patients Advocacy and community mobilisation for TB/HIV/AIDS/STD control

What has been happening so far ? Policy Environment: Regional TB/HIV Strategy: Final draft Regional Guidelines for Implementation of Collaborative TB/HIV activities: First draft at peer review stage Regional Guidance Kit for HIV/AIDS/STI & TB Community and Home based Care: Final draft Regional Clinical Guidelines for HIV/AIDS Care. Final draft stage Regional VCT Guidelines. Final draft stage

What has been happening so far ?(2) Implementation of TB/HIV activities in Member States: ProTEST & expansion since 1998: Malawi, Zambia, South Africa New Implementation plans: February 2002: Ethiopia, Kenya, Mozambique, Tanzania, Uganda May 2003: Burkina Faso, Chad, Cote D’ Ivoire, DRC, Senegal, Rwanda

What has been happening so far (3) GFATM FUNDING FOR TB/HIV: Round 1: Ethiopia, RSA, Rwanda & Zambia Round 2 (Cat 3): Lesotho, Sao Tome & P, Tanzania, Togo GFATM FUNDING FOR TB: Round 1: Ghana. Round 2: Cat 2: (12 countries):Benin, Chad, DRC, Kenya, Lesotho, Liberia, Mauritania, Mozambique, Namibia, Nigeria, Sierra Leone, Uganda Cat 3 (17 countries): Botswana, Burkina Faso, Burundi, Cameroon, CAR, Cote D ‘ I voire, Equatorial Guinea, Eritrea, Guinea, Lesotho, Rwanda, Sao Tome & P, Senegal, Swaziland, Tanzania, Togo, Zimbabwe

What has been happening so far (4) GFATM FUNDING FOR HIV/AIDS Round 1: 11 countries [Burundi, Ghana, Kenya, Malawi, Nigeria, Senegal, South Africa, Tanzania, Uganda, Zambia, Zimbabwe] Round 2: Cat 1: Madagascar & Swaziland Cat 2: 15 countries [Benin, Botswana, Burkina Faso, CAR, Cote d’Ivoire, Ethiopia, Guinea, Kenya, Lesotho, Liberia, Mozambique, Namibia, Togo, Zanzibar] Cat 3: 13 countries [Cameroon, Chad, Comoros, DRC, Equatorial Guinea, Eritrea, Mauritania, Mauritius, Nigeria, Rwanda, Seychelles, Sierra Leone, South Africa

Developing a strong policy environment and health infrastructure SOME CHALLENGES TO EFFECTIVE TB/HIV/AIDS CONTROL IN THE CONTEXT OF NATIONAL PROGRAMMES Developing a strong policy environment and health infrastructure How to scale up coverage with effective interventions (TB & HIV/AIDS) Ensuring adequate resources (human, drugs, logistics and other) How to unify efforts to cater for common clients (TB & HIV/AIDS suspects and patients) Positioning to take advantage of new opportunities

Opportunities for scaling up Health sector reforms in countries GDF for TB. Could use similar approach for ARVs? World Bank MAP Projects GFATM funding Bilateral funding initiatives US President’s pledge for HIV/AIDS support New drug development initiatives

Where do we go from here ? In the light of the magnitude of the TB/HIV problem in Africa, the prevailing socio-political landscape and the responses to-date, what should African countries be doing to achieve TB control in the face of the HIV/AIDS epidemic ?