Tuberculosis and the President’s Emergency Plan for AIDS Relief 12/9/2018 Tuberculosis and the President’s Emergency Plan for AIDS Relief Bess Miller Associate Director, TB/HIV Global AIDS Program Centers for Disease Control and Prevention 4th Global TB/HIV Working Group Meeting 20-21 September, 2004 Addis Ababa, Ethiopia

Outline of Presentation The President’s Emergency Plan for AIDS Relief Who?, What?, Where? TB/HIV and The President’s Emergency Plan Where are the linkages? How will this translate into action at country level? Operationalizing TB/HIV activities in the context of ARV Programs Challenges and Opportunities

Collaboration Across the U.S. Government to Fight Global AIDS 12/9/2018 Collaboration Across the U.S. Government to Fight Global AIDS State Department Office of the Global AIDS Coordinator (OGAC) USAID Embassies Department of Health and Human Services CDC NIH HRSA FDA Departments of Defense, Labor, and Commerce Peace Corps The U.S.G response to the epidemic: Three HHS agencies are currently involved in global HIV/AIDS activities: CDC, which has the lead role for the department; NIH, which sponsors a variety of research with US and international academic institutions; and HRSA, which helps build capacity in treatment and care. HRSA receives approximately $3M from CDC for that effort. Re: Global Fund – With HHS Secretary Tommy Thompson now the Board Chair, the US government’s role will be more prominent. Already, GAP and USAID staff have worked with host country governments to develop their applications to the Global Fund – many of which were successful in securing funding. NASTAD provided TA to China and Guyana for their Global We will continue working with host countries to provide essential technical assistance and expect NASTAD members will play a role in that. As you know, Global Fund monies come without technical assistance, and we feel strongly that, for programs to have their greatest effect, CDC and USAID staff, as well as other donors and NGOs, will need to provide assistance in program development, implementation and evaluation.

The President’s Emergency Plan for AIDS Relief Announced January 28, 2003 15 focus countries Goals: Treat 2 million HIV-infected people Prevent 7 million new HIV infections Provide care for 10 million HIV-infected people and AIDS orphans

The President’s Emergency Plan for AIDS Relief Three Tiers Leadership in HIV/AIDS in all countries Strong bilateral HIV/AIDS programs in ~100 countries Focused attention in 15 countries

The President’s Emergency Plan for AIDS Relief 15 Focus Countries

The President’s Emergency Plan for AIDS Relief Implementation To be implemented as a single USG program coordinated by the Global AIDS Coordinator Coordinates with other donors at HQ and country level Works within national plans of countries To be implemented based on a "network model“ of health care delivery PLANNING IS DONE AT COUNTRY LEVEL

Legislative Mandate for Distribution of The Emergency Plan Funds Orphans & Vulnerable Children 10% Prevention 20% Treatment* 55% Palliative Care 15% Overall budget: $15 billion over 5 years **75% of treatment funds should be for purchase and distribution of ARVs Source: Public Law 108-25

Eight of the 15 Focus Countries are Among the 22 high TB Burden Countries. Ethiopia Kenya Mozambique Nigeria South Africa Tanzania Uganda Vietnam

TB in Emergency Plan Focus Countries 13 of 15 have had large annual increases in TB incidence since 1997 Over 435,000 HIV-infected persons with active TB in the 15 countries In Namibia, South Africa, and Zambia >60% of adult TB patients are HIV+ In Botswana 79% of adult TB patients are HIV+

How can TB DOTS Programs Contribute to Meeting Goals of the President’s Emergency Plan? Readily identifiable candidates for ARV therapy (Treat 2 million…) Readily identifiable candidates for OI treatment and prevention, including TB (Provide care for 10 million…) Model program for developing ARV programs Sites for routine HIV counseling and testing and referral to HIV care, partner testing (Prevent 7 million…)

Priority TB/HIV Activities for PEPFAR Countries -1- HIV C & T all TB patients Screen all HIV+ for active TB Establish referral systems Improve TB diagnostic capabilities in healthcare facilities and labs serving HIV-infected patients

Priority TB/HIV Activities for PEPFAR Countries -2- Improve adherence to treatment – Work with AIDS CBO’s, FBO’s, NGO’s Strengthen TB/HIV surveillance systems Include IPT for HIV+ Facilitate coordination of TB-HIV collaborative activities

Priority TB/HIV Activities for PEPFAR Countries -3- Implement basic TB infection control policy for settings caring for both patients with HIV/AIDS and active TB Cross-train health workers in TB and HIV Evaluate TB/HIV activities – TB/HIV referral systems – TB treatment completion in TB/HIV patients

Guidance for HIV Caregivers Managing TB Starting ARV in TB patients Contacting the NTP Screening for TB Referring and tracking TB patients Infection control Preventing MDR TB

When to Start ARV in TB Patients 12/9/2018 When to Start ARV in TB Patients CD4 < 200 mm3 – Start ARV between 2 weeks and 2 months CD4 200-350 mm3 – Start ARV after initiation phase CD4 > 350 mm3 – Defer ARV CD4 unavailable – Start ARV based on clinical evaluation of immune status For all, timing of ART should be based on clinical judgment in relation to other signs of immunodeficiency For EP TB, start ART as soon as possible, irrespective of CD4 For cd4>350, would start ART if OTHER conditions of stage IV present WHO, Scaling Up ARV, 2003 Revision

Contacting the NTP Contact NTP when establishing HIV care programs Report all new cases of TB to NTP Meet with NTP on a regular basis

Screening for TB Develop TB symptom screen questionnaire Train hcws on administration of questionnaire and on signs/symptoms of TB Identify convenient site(s) for further TB diagnostic evaluation

Referring and Tracking TB Patients Develop tracking system for patients referred for TB dx and rx. Monitor success rates of referrals Identify TB/HIV coordinator in HIV Care program to follow up referred TB patients Meet with NTP on a regular basis

Addressing TB Infection Control Develop TB Infection Control Plan Identify staff member/team to oversee infection control practices Develop triage and evaluation plan for suspect TB patients in outpatient settings Do not treat MDRTB in HIV care setting Educate health workers and patients WHO, Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-Limited Settings, 1999

in an Outpatient Clinic Poorly Ventilated Waiting Area in an Outpatient Clinic

Alternative for Waiting Area Maximize Natural Ventilation

Preventing MDRTB “A poor TB control program is worse than no TB control program.”

Preventing MDRTB For patients on TB drugs and ARV, don’t discontinue any TB drugs without evidence of significant side effects. Never add a single anti-TB drug to a failing TB regimen. Monitor patients who have been referred for TB treatment closely. Prevent treatment default. Meet with the NTP on a regular basis.

Thank you!