TB/HIV: Global Progress in Implementation and Challenges Diane V. Havlir, MD University of California, San Francisco, CA Diane V. Havlir, MD University of California, San Francisco Chair, HIV/TB Working Group of the STOP TB Partnership

Overview Progress over the last year Core Group Activities Global Reports Evaluation of Working Group Activities What next for the Working Group?

Mission of the HIV/TB Working Group Reduce global burden of HIV/TB through effective collaboration between TB and HIV communities, establishing policies, targets, monitoring and evaluations for evidence based collaborative HIV/TB activities

Goals Catalyze nationwide expansion of HIV/TB activities in more countries, with regional focus on Asia Pacific and Africa Promote implementation of Three Is for HIV/TB by all HIV stakeholders Improve and harmonize monitoring & evaluation across UN agencies and partners Raise research interest and investment Raise global visibility of HIV/TB Increase HIV civil society response to TB/HIV

Progress since last meeting 30/33 action items from 14th Core Group meeting completed - 3/33 not completed Highlights of activity TB/HIV Research priorities discussed by HIV experts Highlighted by influential leaders Harmonization of M&E indicators for TB/HIV Meta-analysis of ICF screening completed TB/HIV visibility in political arena (maintenance of resources in financially critical time) and presence at HIV meetings TB/HIV key priority for UNAIDS framework for action

Latest global TB estimates Estimated number of cases Estimated number of deaths 1.77 million (27 per 100,000) 9.27 million (139 per 100,000) ~150, ,000 All forms of TB Greatest number of cases in Asia; greatest rates per capita in Africa Multidrug-resistant TB (MDR-TB) Extensively drug- resistant TB (XDR-TB) ~50,000 ~30,000 HIV-associated TB 1.4 million 500,000

The WHO 12 points policy package B. To decrease the burden of TB in PLWHA 5. Intensified TB case finding 6. Isoniazid preventive therapy 7. TB infection control in health care and other settings A. Establish the mechanism for collaboration 1. TB/HIV coordinating bodies 2. HIV surveillance among TB patient 3. TB/HIV planning 4. TB/HIV monitoring and evaluation C. To decrease the burden of HIV in TB patients 8. HIV testing and counselling 9. HIV preventive methods 10. Cotrimoxazole preventive therapy 11. HIV/AIDS care and support 12. Antiretroviral therapy to TB patients. Joint HIV and TB HIV programme TB programme 6A ANTIRETROVRAL THERAPY

No reported activity < 15% 15 to 50% 51 to 74% More than 75% Proportion of TB patients tested for HIV Key % 22%37%48% 2008 The map for 2008 is preliminary and does not show actual colours of implementation in all countries HIV testing is becoming a standard care for all TB patients HIV Testing for Notified TB Patients

HIV testing of TB Patients in India

Global implementation of key TB/HIV activities Data for 2008 is preliminary and does not include data from European region Global Implementation of key HIV/TB Activities

TB screening, treatment and IPT Data for 2008 is preliminary and does not include data from European region By 2008, 1 out of 4 estimated HIV positive TB patients were identified and put on TB treatment

2. What is the impact of the working group? Significant Progress Some Progress Little Progress

Significant Progress (1) HIV/TB Collaborative Activities at Country Level Implementation HIV testing TB screening (algorithms/clinical screening) Monitoring and Evaluation New HIV/TB estimates New and harmonized indicators Harmonized monitoring

Significant Progress (2) Visibility/ Presence of HIV/TB at the international and regional level International AIDS and TB union Conferences Global Fund for HIV/TB, Malaria PEPFAR step up funding for TB/HIV First protest/march HIV/TB Regional: ICCAP and UNAIDS Meeting in Dakar Catalyst of HIV/TB Research Agenda Meetings/Recruitment of young investigators New Report on Research Priorities

Some Progress Infection Control New guidelines Renewed interest in public health/research community Uptake and traction of research agenda not clear Diagnostics Linkages with FIND Roll out of TB testing for HIV population unclear Reporting Made easier with harmonization Still under reporting of HIV/TB activities

Little Progress MDR/XDR Recognition of the problem, but scope not clear Treatment outcomes not clear New drugs in pipeline, not yet readily accessible to HIV population Lack of linkages with incarcerated populations

3. THE HIV/TB Working Group - What Next? SET THE FRAMEWORK HIV/TB Guidelines Community Activism Research priorities SET THE PLAN IN MOTION Heighten visibility Push implementation Improve monitoring Enhance research LETS GET SERIOUS REDUCE TB BURDEN IN HIV POPULATION REDUCE HIV/TB DEATHS Bring in HIV

What are some high impact areas? TB prevention– Widespread ART and IPT We are not utilizing these powerful tools and could work with HIV centers TB diagnostics– Roll out of new technologies We are only identifying and treating ¼ of cases Integration of HIV and TB services Remains a weak link in addressing many implementation goals

Should we focus on HIV centers? High capability to implement TB PREVENTION activities Low Capability for TB DIAGNOSIS Moderate capability to optimize TB TREATMENT

4. Global HIV treatment--Progress WHO/UNAIDS 2009 Report ART– STATUS OF THE ROLL OUT

Reduction in TB case at community level associated with ART HIV infected “off ART” HIV infected “on ART” TB Rates ART coverage Courtesy of Middelkoop, IAS, Late Breaker,2009

Mortality and TB incident cases lower in early vs standard group Mortality decreased by 75% TB decreased by 50% Fitzgerald, ICAAC, 2009

HIV TB Zimbabwe Botswana Adult prevalence of HIV and population notification rate of TB Brian Williams, et al. submitted HIV TB

TB in South Africa if nothing changes Brian Williams, et al. submitted

Impact on TB of testing people in South Africa once a year for HIV and starting them on ART at different CD4 levels. 200/  L 500/  L Immediately 350/  L HIV-negative; including those on ART; including HIV-positive not on ART; total

Starting ART less than five years after infection will rapidly cut the incidence of TB by about 60% to 70%. IPT could given an bigger initial reduction. What happens after that depends on what happens to HIV.

Should we focus on TB treatment centers? Growing infrastructure to diagnose HIV Little infrastructure to treat HIV Some notable exceptions – Africa

Mismatch of TB treatment and HIV testing and ART services in eight countries, 2007 TB treatment facilities (n) HIV testing facilities (n) ART facilities (n) Burkina Faso DR Congo Ethiopia Malawi Myanmar Rwanda Uganda Tanzania For every ART facility there are 5 TB and 3 HIV testing facilities respectively!

Should we focus on integration of HIV and TB services? In theory, this makes great sense Some successful models have emerged One size does not fit all Huge challenges Infection control issues, including health workers Separate administration, management, budget Manpower shortage

Summary HIV/TB remains a global health care crises The Core Group has set a policy framework, pushed these policies in action, raised visibility and improved monitoring of HIV/TB Important areas such as MDR/XDR remain huge threats The core group must define priorities for the coming years that are likely to yield the highest impact

DISCUSSION - What Next? SET THE FRAMEWORK HIV/TB Guidelines Community Activism ? Research SET THE PLAN IN MOTION Heighten visibility Push implementation Improve monitoring Enhance research LETS GET SERIOUS REDUCE TB BURDEN IN HIV POPULATION REDUCE HIV/TB DEATHS