Exploring Synergies Health Systems and Sustainability TB/HIV collaboration Alasdair Reid UNAIDS Pretoria International Multistakeholder Consultation on National AIDS Programmes Enhancing effectiveness, efficiency and social sustainability Nairobi 19/20 April 2012

Outline Epidemiology History Examples Conclusion

Estimated number of cases, 2010 Estimated number of deaths, million * (0.9–1.2 million) 8.8 million (8.5–9.2 million) ~ 650,000 out of 12 million (11-14 million) prevalent TB cases All forms of TB Multidrug- resistant TB HIV-associated TB 1.1 million (1.0–1.2 million) 350,000 (320,000–390,000) Source: WHO Global Tuberculosis Control Report 2011 ( ) * Excluding deaths attributed to HIV/TB Global Burden of TB

Epidemiology HIV & TB TB incidence in PLHIV about 5-10% per year 1 in 4 deaths in PLHIV are due to TB HIV prevalence in TB patients as high as 80%

Incidence of TB per 100,000 population, 2010 Prevalence of HIV among new TB patients, 2010

History of TB and HIV collaboration ProTEST studies in Zambia, Malawi and South Africa 2004 WHO Interim Policy on Collaborative TB/HIV activities – rapid uptake by partners (GFATM, PEPFAR) and over 170 countries by end UNGASS political declaration includes collaborative TB/HIV activities for PLHIV 2011 HLM political declaration sets target of halving TB deaths in PLHIV by WHO Policy on Collaborative TB/HIV activities (GRADE)

WHO Policy on collaborative TB/HIV activities A.Establish and strengthen the mechanisms for delivering integrated TB and HIV services B.Reduce the burden of TB in people living with HIV and initiate early antiretroviral therapy (the Three I’s for HIV/TB) C.Reduce the burden of HIV in patients with presumptive and diagnosed TB –

The updated 12 points policy package B. Decrease the burden of TB in PLHIV through earlier ART and Three Is for HIV/TB 5. Intensify TB case finding and ensure quality TB treatment 6. Introduce TB prevention with IPT and ART 7. Infection control for TB in health care and congregate settings ensured A. Establish the mechanisms for integrated TB and HIV services 1. Set up or strengthen a TB/HIV coordinating body effective at all levels 2. Conduct HIV and TB surveillance among TB and HIV patients respectively 3. Carry out joint TB/HIV planning 4. Conduct monitoring and evaluation C. Decrease the burden of HIV in patients with presumptive and diagnosed TB 8. Provide HIV testing & counselling to patients with presumptive and diagnosed TB 9. Introduce HIV preventive methods patients with presumptive and diagnosed TB 10. Provide CPT for TB patients living with HIV 11. Ensure HIV prevention, treatment & care for TB patients living with HIV 12. Provide Antiretroviral therapy to TB patients living with HIV

A. Establish and strengthen the mechanisms for delivering integrated TB and HIV services A.1. Set up and strengthen a coordinating body functional at all levels A.2. Determine HIV prevalence among TB patients and TB prevalence among PLHIV A.3. Carry out joint TB/HIV planning to integrate the delivery of TB and HIV services – One stop shop – Joint capacity building and engaging NGOs and communities A.4. Monitor and evaluate collaborative TB/HIV activities

One stop shop Large loss to follow up with cross referral even if this is 2 different clinics in the same building Patients referred from TB to HIV clinic for ART took almost 3 times longer (116 days vs 41 days) to start ART compared to those diagnosed with TB in the HIV clinic. – Lawn BMC Infectious Disease 2011 Increase in notification of smear-negative pulmonary and extrapulmonary TB in PLHIV and of treatment success rates thru integration in Lesotho and South Africa – Bygrave H IAS 2010, Brown C CROI 2011 Integrate with other health programmes such as maternal and child health, harm reduction services and prison health services

Joint capacity building & engaging NGOs & communities Hasina Subedar

Joint capacity building & engaging NGOs & communities Trained home-based care and community health-care workers as well as nongovernmental organizations have been successful in providing integrated TB and HIV services in various countries – WHO TB/HIV policy Community-based TB and HIV care services are cost effective – WHO TB/HIV policy

B. Reduce the burden of TB in people living with HIV and initiate early antiretroviral therapy B.1. Intensify TB case-finding and ensure high quality TB treatment B.2. Initiate TB prevention with Isoniazid preventive therapy and early antiretroviral therapy B.3. Ensure control of TB Infection in health-care facilities and congregate settings

TB screening in PLHIV Up to 30% of PLHIV initiating ART have undiagnosed culture confirmed TB. Simple symptom screening very cost effective but misses (10-20%) asymptomatic culture positive TB in new ART patients Laboratory TB screening is highly cost-effective even with 2 GeneXpert tests for every new ART patient – Andrews JR, AIDS 2012 IPT and infection control cost effective – WHO TB/HIV policy

C. Reduce the burden of HIV in patients with presumptive and diagnosed TB C.1. Provide HIV testing and counselling to patients with presumptive and diagnosed TB C.2. Provide HIV prevention interventions for patients with presumptive and diagnosed TB C.3. Provide co-trimoxazole preventive therapy for TB patients living with HIV C.4. Ensure HIV prevention interventions, treatment and care for TB patients living with HIV C.5. Provide antiretroviral therapy for TB patients living with HIV

HIV testing for TB patients National HIV prevalence in TB patients varies significantly (6% -77%) Routine voluntary HIV testing of TB patients in India is effective and cost-effective despite low HIV prevalence in TB patients (2.9-9%) – Uhler LM, PLoS ONE 2010 HIV testing of presumptive TB cases who turn out not to have active TB disease also yields high HIV-positive results – WHO TB/HIV policy High acceptance (74%) of HIV testing among contacts of TB patients in Thailand and a higher (13.8%) HIV prevalence rate among contacts of HIV-positive TB cases as compared with contacts of HIV negative TB cases (2.5%) – WHO TB/HIV policy Opportunity to initiate early ART to HIV positive TB patients and reduce morbidity and mortality (up to 95%) and recurrent TB

South African HCT campaign April June million pre-test counselled 13 million (88%) HIV tested 2 million (16%) tested positive for HIV 8 million (54%) client screened for TB 1 million (13%) referred for TB investigation Over 300,000 PLHIV started on IPT 1.4 million people on ART

Global implementation of key TB/HIV activities (2003 – 2010)

Conclusions Evidence based programme integration can increase efficiency and effectiveness and respond better to client needs Rapidly taken to scale Integration itself is low cost Good evidence of efficiency and effectiveness of the individual elements of the collaborative policy but no studies examining cost-effectiveness of full package of integration - do we need them?

Acknowledgements IAS H. Getahun D. Sculier T. Hiatt H. Subeda

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