Paul Nunn, STOP TB WHO, Geneva The 2nd Meeting of the Global Working Group on TB/HIV Durban, June 14-16, 2002 Progress 2001-2002 Paul Nunn, STOP TB WHO, Geneva

Contents Summary of the state of the epidemic Recommendations and practical results Review of the environment Future directions

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

Summary HIV/TB - 2000 L Corbett et al. Arch. Int. Med. In press. 2002 Africa below the Sahara holds nearly one fourth of the world’s incident TB, and this is rising at >3% p.a. However it contains >80% of the world’s HIV associated TB burden. Over 50% of the half a million deaths occurring with TB in Africa are in the HIV infected. Around 12% of all HIV/AIDS related deaths are due to TB L Corbett et al. Arch. Int. Med. In press. 2002

Countries ranked by the estimated number of TB cases attributable to HIV (thousands) - 2000 Above red line: 80% of total number; above black line: 90% of total number Rank Country Number Rank Country Number 1 S. Africa 77.8 16 Rwanda 7.6 2 Ethiopia 59.2 17 B. Faso 6.5 3 Nigeria 49.9 18 Burundi 6.4 4 Kenya 43.9 19 Ghana 6.0 5 India 41.4 20 Thailand 5.6 6 Zimbabwe 29.2 21 Botswana 5.5 7 Tanzania 25.2 22 CAR 4.9 8 DR Congo 22.6 23 Myanmar 4.9 9 Mozam. 21.5 24 Lesotho 4.8 10 Zambia 18.9 25 Haiti 3.7 11 Uganda 17.3 26 Angola 3.1 12 Malawi 16.1 27 Namibia 3.1 13 C. d'Ivoire 15.0 28 China 2.9 14 Cameroon 10.1 29 Togo 2.4 15 Cambodia 7.7 30 USA 2.3 Brian Williams kindly prepared this slide for me which summarises the burden of HIV associated TB and ranks it by country. The approach is analagous to that that defines the 22 highest burden countries with TB. Africa once again stands out as the focus of this problem - India is listed at No. 5 because of its huge population, and is the only non-African country in the top 14. Cambodia is the worst-affected Asian country after India, followed by Thailand and Myanmar. Haiti is the highest ranked country in the Americas. There are alternative ways of presenting this kind of data, and these will be addressed In Brian Williams’ presentation on Sunday.

THE FORM of the Global TB/HIV WG Stop TB Governance Structure New TB Drugs TB/HIV DOTS-Plus MDR-TB Diagnostics DOTS expansion W O R K I N G G R O U P S Vaccines Stop TB Partners’ Forum Global TB Drug Facility Coordinating Board Partnership Secretariat WHO Technical Advisory Group Cross-cutting issues: Advocacy & Communications/ Financing

Recommendations of WG - 2001 Policy development Finish WHO/UNAIDS Strategic Framework WG partners to promote national TB/HIV activities District-level phased implementation of joint TB & HIV/AIDS programme activities Prepare operational guidelines WG partners to enhance TB and HIV/AIDS collaboration at international level Continued support for ProTEST Identify other TB/HIV joint activities GA and WHA resolutions Mobilise resources

Recommendations 2001 Develop 5 year workplan WG partners to promote and support research 2nd meeting of WG to review progress in implementation of recommendations and setting future direction

Policy Development Strategic framework Analysis of interaction between TB and HIV/AIDS programmes in sub-Saharan Africa Report of the First WG meeting Distributed 4th World Congress Barcelona AIDS Conference Media UNAIDS and WHO lists Work in progress: Mathematical modelling of impact of interventions Review of the epidemic of TB and HIV and implications Review of the impact of HIV on recurrence and relapse of TB and recommendations for policy

Promotion of National TB/HIV Activities Phased implementation of district level joint TB & HIV/AIDS activities Nairobi workshop, February (AFRO,CDC-GAP,USAID) Country support, Ethiopia, Kenya, Zambia, Mozambique, Tanzania Mentors WHO staff Evaluation of ProTEST Behavioural Cost-effectiveness Operational guidelines for national and district use Development of standardised data collection instruments Review of proposals by Scientific Panel of WG, July Review and completion of operational guidelines by SP Partner support, eg CDC-GAP (Zambia) USAID (Ethiopia) WHO “Brokerage” of support, eg GFATM World Bank

Enhancement of TB and HIV/AIDS collaboration at international level Expanding collaboration within WHO HQ TB focal points Joint staff Joint approach to country support, GFATM & WG GA and WHA resolutions Failed Continued support for ProTEST Identification of other TB/HIV joint activities Establishment of WG core group Work in progress Mobilise resources Database Assistance with GFATM proposals

And... Promotion and support of research Working paper in preparation on priorities Development of a 5 year workplan Planned Organisation of 2nd Global TB/HIV WG meeting Review of progress in implementation of recommendations Future direction of activities

External environment Key Happenings: Implications: Commission for Macroeconomics and Health GFATM ?3 TB/HIV projects supported World Bank, HIPC and PRSP Shift in HIV community to “care” and hence openness to TB Shift in TB community to address HIV as driving force of TB epidemic Implications: Financial resources need not be rate-limiting Countries are in the driving seat Demand for high quality technical support remains Human resources are key bottleneck

Future Directions - Recommendations Continued focus on country support Close collaboration with HIV/AIDS community Close collaboration with DOTS Expansion WG Continue to build evidence for joint TB & HIV programme activities Focus WG’s global efforts on 25 countries with 90% of the TB/HIV burden Approach Nigeria and Zimbabwe Continue with plan for francophone workshop Consider India and other large countries Work with RO’s on countries outside Africa Continue to seek financial resources Start to address human resource constraints

Ways of Working - Recommendations Improve terms of reference of WG Strengthen core group and focus on strategic direction of WG Strengthen partnership Increase human resources Address financial resources

Work-plan of partners Agreement on technical strategy Agreement on geographic focus - for debate Country level plans - begun, requires further planning What, how, by whom, when? Costing Identification of sources of support - begun, requires further work for WG activities for technical support, co-ordination for implementation Financial gaps - to be defined

“There is a tide in the affairs of men, Which, if taken at the flood, leads on to fortune; …..On such a full sea are we now afloat; And we must take the current when it serves, or lose our ventures.” W. Shakespeare (Julius Caesar)

Acknowledgements Dermot Maher, Philip Onyebujoh, Fabio Scano, Brian Williams Elyse Kingery, Zahra Ali-Piazza, Nellie Courcoulas, Linda Clemensson Charlie Gilks, Massimo Ghidinelli, Bernhard Schwartlander Vainess Mfungwe, Wilfred Nkhoma, Eugene Nyarko Leo Blanc, JW Lee, Mario Raviglione Patrick Bertrand Petra Heitkamp, Michael Luhan