Guidelines for implementing collaborative TB and HIV programme activities Fabio Scano Stop TB Department World Health Organization Durban, South Africa TB/HIV WG meeting, 14-16 June 2002

Outline of presentation The problem and the response The rationale for the guidelines WHO are these guidelines for? WHAT TB and HIV/AIDS programmes should implement HOW to implement and WHO should implement joint TB/HIV activities? Challenges Next steps

Estimated HIV-MTB co-infection prevalence, 2000 10 - 99 100 - 999 1000 - 4999 < 5 5 - 9.9 5000 or more No estimate Rate per 100 000 Source: Corbett EL, Watt CJ, Walker N, Maher D, Raviglione MC, Williams B, Dye C. (submitted for publication).

Africa: HIV is driving the TB Epidemic TB Notification Rates, 1980-1999 50 100 150 200 1980 1985 1990 1995 2000 250 300 350 400 450 500 Zimbabwe Malawi Tanzania Côte d'Ivoire Kenya Years Rate (x100,000) World Health Organization

The problem (cont) HIV is driving the TB epidemic in many countries (sub-Saharan Africa) Tuberculosis in high HIV prevalence populations is a leading cause of morbidity and mortality among HIV-infected patients

The response The international response to TB/HIV is evolving: Previously - “A dual strategy for a dual epidemic” TB and HIV/AIDS programmes have largely pursued separate courses, despite overlapping TB/HIV epidemiology. Now - Strengthened unified health sector strategy to control TB/HIV as an integral part of the response to HIV/AIDS.

The response (cont) Expanded scope of new strategy to control TB in high HIV prevalence populations includes:  Full implementation of the DOTS strategy  Additional interventions against TB: Intensified TB case-finding and treatment, TB preventive treatment  Interventions to decrease HIV transmission, e.g. condom promotion, STI treatment, safe injecting drug use and ARTs (to restore the immune system).  interventions to decrease morbidity and mortality in HIV-infected TB patients e.g. cotrimoxazole preventive treatment, OI treatment

The rationale Most districts see the need for reducing the burden of the overlapping TB and HIV epidemic, but may not be aware of potential collaborative TB and HIV activities and their benefits

WHO are these guidelines for? 1. District policy-makers and health providers: -Simple, practical -Evidenced-based -Adaptable -Enable rational planning, priority setting 2. National policy makers and programme managers: -Policy consensus and strategy -Advocacy -Technical assistance

WHAT should TB and HIV/AIDS programmes implement? Collaborative TB and HIV programme activities: -Building on the TB and HIV interventions in the expanded scope of the new strategy for TB control -Prioritisation of TB/HIV interventions -Learning through the process of implementation

HOW to implement collaborative TB and HIV programme activities Steps outlined in the guidelines: 1. Situation analysis: Baseline data (as much as possible using existing data) Existing services (checklist: which providers are delivering which element) 2. Co-ordination of stakeholders (co-ordinating body, TB/HIV committee) 3. Development of district work-plan with objectives and budget for each partner 4. Costing activities (using existing resources; requiring more resources; requiring new resources) 5. Steps to implement activities (prioritised-activity charts and implementing activity boxes) 6. Monitoring and evaluation

Steps to implement activities Prioritised-activity chart Each prioritised-activity-chart describes likely prioritisation of collaborative TB/ HIV activities according to human and material resources required and capacity building of each of the following health care provider within the district: • TB Health care provider • VCT • PLHA support group • STI care provider • HBC services • Primary health care centre • District hospital • HIV clinic

Prioritised-activity charts: TB Health care provider DOTS Programme Regular drug supply DOT system Cure rate... …. Sm+ identified start treatment - HIV health promotion to TB patients TB/HIV IEC materials VCT promotion to TB patients Condom promotion Core activities Group 1 activities (Using existing resources and requiring extra time and planning)

Prioritised-activity charts: TB health care provider (cont) Group 2 activities -Isoniazid preventive therapy (requiring more resources) -Intensified TB case finding -VCT clients -Household contacts Group 3 activities -Cotrimoxazole preventive therapy (requiring new resources) -ARVs (??)

Implementing-Activity Box One-page outline which describes the policy issues and activities required at central and district level to support implementation of each of the following collaborative TB/HIV activities

Implementing-Activity Boxes 1. Promotion of VCT to TB, HBC and STI patients 2. Promotion of safer sexual practices and condoms to TB patients 3. Intensified TB case-finding by NTP partner 4. Cotrimoxazole preventive therapy 5. TB screening at VCT centres 6. STI screening at VCT centres and VCT promotion by STI treatment services 7. STI treatment at VCT centres 8. TB sputum smear-microscopy at stand-alone VCT centres 9. TB treatment at stand-alone VCT centres 10. Community involvement in TB treatment 11. PLHA support group involvement in TB (or STI) activities 12. Isoniazid preventive therapy-example of implementation at a stand-alone VCT centre 13. Anti-retroviral treatment (ART)

Monitoring and evaluation Data collection as much as possible within routine systems guidelines to suggest indicators for each intervention development of standardised data collection tool including those for cost-effectiveness measurement Reporting at district level to the partners to the national level Annual review and preparation of next annual work-plan

Challenges a) learning by doing b) modelling studies  To prioritise interventions: a) learning by doing b) modelling studies  To develop capacity to deliver interventions  Cost-sharing and resource mobilisation  Effective co-ordination of many role players

Process  July 2001: Requested by STAG-TB.  September 2001: Scientific Panel of the TB/HIV WG convened to discuss components of the guidelines.  January 2002: first revision  February 2002: Guidelines utilised as a background document to develop proposal at the Workshop for PIAs in Nairobi (Malawi, South Africa, Uganda, Zambia, Ethiopia, Kenya, Mozambique and UR Tanzania)  May 2002: Second full revision completed including contributions from HIV/AIDS department

Next steps  June 2002: Seek endorsement by TB/HIV WG and STAG-TB  Q-3, 2002: Guidelines finalisation  Q-3, 2002: Development of standardised data collection system  Q-4, 2002: Guidelines to be field tested  Q-4, 2002: Country proposals evaluation  Q-1, 2003: Development of training tools to be utilised in conjunction with the guidelines and standardised data collection throughout phased implementation

List of contributors and reviewers Scientific Panel members: Francis Adatu-Engwau, Kenneth Chebet, Gijs Elzinga, Paula Fujiwara, Larry Gelmon, Peter Godfrey-Faussett, Nicola Hargreaves, Bess Miller, Jintana Ngamvithayapong-Yanai, Jeroen van Jorkom, Mukadi Ya Diul Co-ordinators of the TB/HIV pilot sites: Helen Ayles, Laura Campbell, Rhehab Chimzizi, Rokoya Ginwalla, Nicola Hargreaves, Harry Hausler, Rose Hegner, Barbara Karpakis, Julia Kim, Barudi Mosimaneotsile, Pren Naidoo, Paul Proynk, Carol Sheard, Jacky Sallet, Mukadi Ya Diul, Rony Zachariah. Other reviewers: Rachel Baggaley, Antony Harries, Steve Graham, Miriam Taegtmeyer