Involving all health care providers in collaborative TB/HIV activities Eva Nathanson PPM subgroup meeting Cairo, Egypt, 3-5 June 2008

Background TB is a leading cause of death among people living with HIV At least one-third of the 33 million people living with HIV are also infected with TB and at great risk of developing TB disease In 2006, WHO estimated 710,000 new TB cases and 230,000 TB deaths in people living with HIV

Geographical distribution of HIV-positive TB cases, 2006 The African Region accounts for 85% of the global distribution of HIV-positive TB patients

Estimated HIV prevalence in new TB cases, 2006 No estimate 0–4 20–49 50 or more 5–19 HIV prevalence in TB cases, (%)

Why PPM TB/HIV Joint Meeting of the DOTS Expansion, TB/HIV and MDR-TB Working Groups of the Stop TB Partnership, Versailles, France, October PPM for TB/HIV recognized as an untapped opportunity to scale up collaborative TB/HIV activities Literature review on PPM and TB/HIV revealed potential for improved and equitable access to TB/HIV services through engagement of non- public health care providers in collaborative TB/HIV activities

TB/HIV collaborative activities A.Establish the mechanism for collaboration A.1. TB/HIV coordinating body A.2. HIV surveillance among TB patients A.3. TB/HIV planning A.4. TB/HIV monitoring and evaluation B. To decrease the burden of TB in PLWHA B.1. Intensified TB case finding B.2. Isoniazid preventive therapy B.3. TB infection control C. To decrease the burden of HIV in TB patients C.1. HIV testing and counselling C.2. HIV preventive methods C.3. Cotrimoxazole preventive therapy C.4. HIV/AIDS care and support C.5. Antiretroviral therapy to TB patients Main responsibility of national AIDS and TB control programmes but with engagement of all care providers Engagement of different health care providers needed

Current evidence Lack of strong evidence Potential for improved and equitable access to TB/HIV services through engagement of non-public health care providers in collaborative TB/HIV activities Urgent need for more research and documentation of ongoing initiatives

Location and type of providers ProviderCollaborative TB/HIV activities provided by non-public providers KenyaFaith based organizationIntensified TB case finding HIV testing and counseling ART and TB treatment support IndonesiaPrivate not for profit clinicHIV testing and counseling CambodiaFamily Health InternationalReferral KenyaPrivate Practitioners and NGOsReferral Malawi South Africa Zambia NGOIntensified TB case finding Referral Provision of CPT and IPT MalawiMédecins sans frontièresReferral by community volunteers TanzaniaNGOHIV testing and counseling Intensified TB case finding DOT Referral South AfricaCorporate Sector TB diagnosis HIV testing and counseling TB treatment PPM TB/HIV publications with quantitative data

HIV testing rates in a private TB clinic, Jakarta, Indonesia,

PPM TB/HIV progress to date First TB/HIV PPM consultation, Geneva, Switzerland, May Guiding principles for PPM and TB/HIV developed Consultative Workshop to promote the engagement of all health care providers in TB/HIV, February 2008, Geneva, Switzerland -Protocol for the implementation of PPM TB/HIV activities developed

Guiding principles for PPM and TB/HIV Political commitment Coordination between national AIDS and TB programmes and private and public stakeholders involved in the initiative Advocacy to involve all providers and to ensure buy-in of relevant stakeholders in PPM TB/HIV Drugs and consumables supplied free of charge to the providers should be provided free of charge to the patients Diagnostic tests should be accessible and affordable Capacity building should be in line with national policies and standards Build on existing collaboration between private and public sector and national TB and AIDS control programmes Ensure the provision of technical assistance Ensure continuity of services to end users should providers dropped out

Protocol for the implementation of PPM TB/HIV activities Aims at providing practical and generic steps to National AIDS and TB control programmes to initiate, expand and document the engagement of private and public service providers for collaborative TB/HIV activities Includes -Planning -Preparation -Implementation -Monitoring and evaluation

Challenges Differences between HIV and TB communities Harmonizing access between services Supply management Setting up referral and recording and reporting systems Human resources for the coordination and supervision of PPM TB/HIV activities Quality of services

Next steps Publication of the TB/HIV PPM literature review Finalization and dissemination of the protocol for the implementation of PPM TB/HIV activities WHO and partners should encourage the use of the protocol to set up demonstration projects for implementing TB/HIV PPM activities With financial support from the TB Coalition for Technical Assistance, and in collaboration with partners, the UNION will support TB/HIV PPM projects in India and Namibia The evidence and experience gathered by using the protocol should contribute to a policy on the engagement of all care providers in the fight against TB/HIV

Thank you!