Strategic framework for TB/HIV Dermot Maher Stop TB Department World Health Organization Geneva, Switzerland On behalf of the Global TB/HIV Working Group IUATLD World Conference on Lung Health Montreal October 2002

Outline of presentation Why a strategic framework to control TB/HIV? TB as part of the HIV/AIDS epidemic Why joint TB and HIV/AIDS programme activities? What interventions are available against TB/HIV? Current status of implementation of interventions A coherent health service response to TB/HIV Essential package of HIV/AIDS care From framework to implementation What is needed for comprehensive action?

The burden of HIV-related disease At any stage High-grade pathogens, e.g. pneumococcus, non-typhoid salmonellae, Mycobacterium tuberculosis More advanced immunosuppression Low-grade pathogens, e.g. candida, Cryptococcus neoformans, toxoplasma, Pneumocystis carinii, atypical mycobacteria

How does HIV fuel the TB epidemic? 1. Promotes progression to TB of Mycobacterium tuberculosis infection - recently acquired - latent (most powerful known risk factor) In people co-infected with HIV and Mycobacterium tuberculosis, annual risk of TB = 5-15% 2. Increases rate of recurrent TB (endogenous/exogenous) 3. Increased TB cases in HIV-infected people pose risk of TB transmission to general community.

TB/HIV overlapping epidemics The impact of HIV on the TB epidemic depends on the size of the overlap between the M tuberculosis infected and HIV infected populations Mycobacterium tuberculosis HIV overlap Region HIV epidemic TB/HIV epidemic TB/HIV HIV epidemic overlap Africa generalised +++ North America concentrated (IDU, MSM) + Western Europe North concentrated (MSM) – South concentrated (IDU) + Eastern Europe concentrated (IDU) + TB and HIV

Dynamics of TB and HIV in Uganda 160 35 140 30 120 25 100 20 HIV-national 120 25 HIV-Kampala 100 20 HIV prevalence adults (%) TB incidence/100,000 80 15 60 10 40 5 20 1975 1980 1985 1990 1995 2000

A key fact At least 1 in 3 people with HIV will develop TB

Implication for HIV/AIDS Programmes TB is a huge part of HIV/AIDS care

Implication for TB Programmes Prevention of HIV is crucial to control TB

Evolving international response to TB/HIV? Previously - “a dual strategy for a dual epidemic” (UNAIDS) TB and HIV/AIDS programmes have largely pursued separate courses Now - unified health sector strategy Controlling TB/HIV as an integral part of response to HIV/AIDS.

Sequence of events in transmission of TB Transmission of infection M. tuberculosis infection Recurrence after treatment Inadequate treatment M. tuberculosis infected person Untreated Active TB TB progression TB reactivation

Sequence of events by which HIV fuels TB Transmission of infection M. tuberculosis infection HIV infection Recurrence after treatment Inadequate treatment M. tuberculosis infected person Untreated Active TB TB progression TB reactivation

Main biomedical interventions against M tuberculosis Transmission of infection M. tuberculosis infection TB preventive treatment HIV infection Recurrence after treatment BCG Rifampicin containing regimens Inadequate treatment M. tuberculosis infected person  Intensified case-finding  Decreased diagnostic & treatment delays Untreated Intervention against M.tuberculosis Active TB TB progression Sequence of events: HIV-negative HIV-positive TB reactivation TB preventive treatment

Main interventions to interrupt the sequence of events by which HIV fuels TB Transmission of infection M. tuberculosis infection TB preventive treatment HIV infection Condoms STI treatment Safe IDU Recurrence after treatment BCG Rifampicin containing regimens Inadequate treatment M. tuberculosis infected person  Intensified case-finding  Decreased diagnostic & treatment delays HAART Untreated Intervention against HIV Intervention against M.tuberculosis Active TB TB progression Sequence of events: HIV-negative HIV-positive TB reactivation TB preventive treatment

Expanded scope of new strategy to control TB in high HIV prevalence populations Intensified TB case-finding and treatment Additional measures beyond TB case-finding and treatment TB preventive therapy Interventions to decrease morbidity and mortality in HIV-infected TB patients Interventions to decrease HIV transmission ARV therapy

Status of implementation of interventions in sub-Saharan Africa in 2001 1) Condoms annual provision = 5 per man per year (17 in top 6 countries) 2 billion per year needed for all countries to match top 6 (Shelton JD, Johnston B. Br Med J 2001; 323: 139)

HIV-infected people treated with HAART = 30,000 2) Antiretrovirals HIV-infected people treated with HAART = 30,000 (out of 30 million)

3) NTP performance in 24 countries with adult HIV seroprevalence > 5% Countries achieving WHO target successful treatment rate of 85% (corrected for high case fatality) Malawi Haiti (40%)

A coherent health service response to TB/HIV (1) Strengthened TB programme activities Strengthened HIV/AIDS programme activities Joint TB and HIV/AIDS programme activities planning surveillance training staff drug supply and other logistics case detection and management

A coherent health service response to TB/HIV (2) Essential package of HIV/AIDS care in low-income countries Interventions including TB interventions at relevant levels of health care system: home and community care primary care secondary care tertiary care Criteria for prioritisation, e.g. cost-effectiveness TB treatment is one of the most cost-effective HIV/AIDS interventions (Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Creese et al. Lancet 2002; 359: 1635-42)

From a strategic framework to national implementation strategies Stop TB Dept HIV/AIDS Dept UNAIDS national partners field experience (e.g. ProTEST Initiative) national implementation strategy strategic framework wide consultation and endorsement by Global TB/HIV Working Group the evidence for what is possible who does what, when, with which funds, from where?

Needs in strengthening general health service providers Increased funding for improved general health service provider capacity (human resources, infrastructure, commmodities) Shift in policy: away from vertical HIV/AIDS services towards a strengthened response to meet the needs of high HIV prevalence populations Operational research on TB and HIV programme collaboration in supporting health providers Effective coordination of many role players

Conclusion Increasing aid flows for priority diseases of poverty (AIDS, TB and malaria): HIPC GF ATM Foundations, e.g. Gates commitment + $ + action -> results