Policy review of HIV and TB guidelines for high HIV/TB burden African countries HIV/AIDS Department World Health Organization

WHO 2010 ART guidelines Target PopulationART guideline HIV+ asymptomatic patients ARV-naïve individuals CD4 < 350 cells/mm 3 HIV+ pregnant womenCD4 < 350 cells/mm 3 irrespective of clinical symptoms or WHO clinical stage 3 or 4 irrespective of CD4 cell count HIV/TB co-infection ARV- naïve individuals Presence of active TB, irrespective of CD4 count

WHO 2004 Interim Policy on Collaborative TB/HIV Activities A. Establish NTP-NACP collaborative mechanisms  Coordinating bodies for effective TB/HIV activities at all levels  Conduct surveillance of HIV prevalence among TB cases  Carry out joint TB/HIV planning  Monitor and evaluate collaborative TB/HIV activities B. Decrease burden of TB among PLHIV (the "Three I's for HIV/TB")  Establish intensified TB case finding  Introduce INH preventive therapy  Ensure TB infection control in health care and congregate settings C. Decrease burden of HIV among TB patients  Provide HIV testing and counselling  Introduce HIV prevention methods  Introduce co-trimoxazole preventive therapy  Ensure HIV/AIDS care and support  Introduce ARVs

 Use of four-symptoms screening algorithm to rule out active TB and offer IPT  Four symptoms include cough, fever, weight loss and night sweats  Past history of TB and current pregnancy should not be contraindications for IPT  TST or chest radiography are not required WHO 2010 IPT/ICF Recommendations

Estimated 2009 HIV/TB and HIV burden Source : 2010 Stop TB global surveillance report, UNAIDS Report on global AIDS Epidemic 2010 CountryPeople with HIV-Figure in '000 (% of global HIV- positive people) People with HIV and TB- Figure in '000 (% of global HIV/TB burden) People eligible for ART at CD4 < 350 cells ('000) People on ART ('000) ART coverage (%) People living with HIV screened for TB ('000) ART coverage (%) Botswana320 (1.0)6.8 (0.6) EthiopiaN/A34 (2.8)N/A176.6N/A Kenya1500 (4.5)53 (4.4) N/A Lesotho290 (0.9)8.7 (0.7) N/A Malawi920 (2.8) 27 (2.3) N/A Mozambique1400 (4.2) 54 (4.5) Namibia180 (0.5) 9.2 (0.8) Nigeria3300 (9.9)87 (7.3) South Africa5600 (16.8) 290 (24.2) Swaziland180 (0.5) 10 (0.8) Tanzania1400 (4.2)38 (3.2) Uganda1200 (3.6)54 (4.5) N/A Zambia980 (2.9) 23 (1.9) N/A Zimbabwe1200 (3.6) 48 (4.0) N/A Total (55.5)742.7 (61.9)

Objectives and Methodology Objectives: Compare national HIV, TB and HIV/TB guidelines for 14 African countries with recently released WHO ART and HIV/TB guidelines Methodology: Main guidelines were collected from the following sources:  National HIV Guidelines  National TB Guidelines  HIV/TB and TB infection control Guidelines Standard abstraction form was used to review recommendations on:  ART initiation criteria  The Three I’s for HIV/TB  The Three I's for HIV/TB monitoring and evaluation indicators

Source : National HIV, TB and HIV/TB Guidelines CountryNational ART guidelines National TB control guidelines HIV/TB, ICF, IPT, OI guidelines TB infection control guidelines Botswana Ethiopia Kenya Lesotho Malawi Mozambique Namibia Nigeria South Africa Swaziland Tanzania Uganda Zambia Zimbabwe2010 * Published guidelines, Drafts, Preliminary drafts

ART initiation criteria in people with HIV Country (Year of publication of ART guidelines) Asymptomatic people People with HIV and TBPregnant women Botswana (2008)<250Irrespective of CD4 count<250 Ethiopia (2008)<200<350<200 Kenya (2011)<350Irrespective of CD4 count<350 Lesotho (2007)<350 Malawi (2011)<350Irrespective of CD4 count Mozambique (2010)<250<350 Namibia (2010)<350Irrespective of CD4 count<350 Nigeria (2010)<350Irrespective of CD4 count*<350 South Africa (2010)<200<350 Swaziland (2010)<350Irrespective of CD4 count<350 Tanzania (2009)<200<350<200 Uganda (2008)<250<350 Zambia (2010)<350 Zimbabwe (2010)<350Irrespective of CD4 count*<350 All figures in cells/mm 3, Guidelines in white are similar to WHO recommendations. * Nigeria's TB and HIV/TB guidelines and Zimbabwe's HIV/TB guidelines recommend ART for people with HIV and TB at CD4 count < 350 cells/mm 3

ART initiation for asymptomatic people 2010 WHO Recommendation : CD4 count < 350 cells/mm 3 ≤ 350 ≤ 200 ≤ 250 Kenya, Lesotho, Malawi, Namibia, Nigeria, Swaziland, Zambia, Zimbabwe Botswana, Mozambique, Uganda Ethiopia, South Africa, Tanzania CD4 Count

Zambia recommends ART at CD4 count > 350 cells/mm 3 if any other stage III or IV illnesses Ethiopia recommends ART for all extrapulmonary and disseminated TB patients ART initiation for people with HIV and TB 2010 WHO Recommendation : ART irrespective of CD4 count Irrespective of CD4 count CD4<350 cells BotswanaEthiopia KenyaLesotho MalawiMozambique NamibiaSouth Africa NigeriaTanzania SwazilandUganda ZimbabweZambia

ART initiation for pregnant women with HIV 2010 WHO Recommendation : CD4 count < 350 cells/mm 3 Irrespective of CD4 count CD4<350 cellsCD4<250 cellsCD4<200 cells MalawiKenyaBotswanaEthiopia LesothoTanzania Mozambique Namibia Nigeria South Africa Swaziland Uganda Zambia Zimbabwe Malawi, under Option B+, recommends lifelong ART for all pregnant women irrespective of CD4 count

Co-trimoxazole prophylaxis 2006 WHO Recommendation : CD4 count < 350* cells/mm 3 or WHO stage 3 or 4 CD4< 200 Cells or WHO Stage 3 or 4 Botswana CD4< 350 Cells or WHO Stage 3 or 4 Lesotho, Namibia, Nigeria CD4< 350 Cells or WHO Stage 2, 3 or 4 Mozambique, Tanzania, Zambia, Ethiopia**, Zimbabwe CD4< 200 Cells or WHO Stage 2, 3 or 4 South Africa Different guidelines followed by different countries CD4< 250 Cells or WHO Stage 2, 3 or 4 Uganda All HIV positives Kenya, Malawi, Swaziland *Countries may choose to adopt a CD4 threshold of < 200 cells/mm3 **Source: Ethiopia's Co-trimoxazole prophylaxis guidelines, 2006

National policies for HIV, TB and HIV/TB, and the Three I's for HIV/TB CountryICFIPTTB infection control Indicators on the Three I's for HIV/TB BotswanaNAPNAP, NTP NTP EthiopiaNAP, NTP, HIV/TB NTP, HIV/TBHIV/TB KenyaNAP, OI, NTP x LesothoNAP, NTP NTP MalawiNAP, NTPNAP, NTP**ICNTP MozambiqueNAP, NTP NAP, NTP, ICNAP NamibiaNTPNAP, NTPNTP, IC NigeriaNAP, NTP, HIV/TB NTP, HIV/TB, ICIC South AfricaNAP, NTP, IPT NTP, ICIPT Swaziland*NAP, IPT NAP, ICNAP, IPT, IC TanzaniaNAP, NTP x UgandaNAP, NTP, HIV/TBNTP, HIV/TBNTP, HIV/TB, ICHIV/TB, IC ZambiaNAP, NTP, ICFNTP**, ICFNTP ZimbabweNTP, HIV/TBNTP**, HIV/TB**NTP, HIV/TBx NAP – National ART Policy, NTP – National TB Policy, ICF – National intensified TB case finding guidelines, IPT – National IPT guidelines, IC – TB infection control guidelines, OI – National guidelines on management of HIV-related opportunistic infections Note: * 2011 NTP for Swaziland recommends Three I's for HIV/TB but do not mention any guidelines ** These guidelines do not recommend IPT

CountryICFIPTTB infection control Botswana ✓✓✓ Ethiopia ✓✓✓ Kenya ✓✓✓ Lesotho ✓✓✓ Malawi ✓✓✓ Mozambique ✓✓✓ Namibia ✓✓✓ Nigeria ✓✓✓ South Africa ✓✓✓ Swaziland ✓✓✓ Tanzania ✓✓✓ Uganda ✓✓✓ Zambia ✓✓*✓* ✓ Zimbabwe ✓✗✓ Countries recommending the Three I’s for HIV/TB * Zambia: Preliminary draft on ICF guidelines recommends IPT

TB screening criteria for IPT 2010 WHO Recommendation : Symptom-based screening Note: The map shows IPT initiation criteria recommended by the most recent guidelines for a country

TB exclusion criteria for IPT initiation 2010 WHO Recommendation : Four-symptom screening for cough, fever, weight loss and night sweats * 2011 TB guidelines for Namibia recommend enlarged lymph nodes as an additional symptom ** 2006 TB guidelines for Tanzania recommend chest pain as an additional symptom *** 2008 IPT guidelines for Nigeria recommend weight loss as an additional symptom, 2010 NTP guidelines do not recommend chest X-ray and sputum smear microscopy Cough Night sweats Fever Weight loss Night sweats Chest pain Coughing blood Chest pain Swelling LESOTHO NAP 2007 WHO recommendation SOUTH AFRICA IPT 2010 ETHIOPIA HIV/TB 2008 ZAMBIA IPT 2010 MALAWI NAP 2011 MOZAMBIQUE NAP 2010 TANZANIA** NAP 2009 SWAZILAND NAP 2010 KENYA NAP 2011 Shortness of breath Loss of appetite Shortness of breath Loss of appetite Sputum production Chest pain Coughing blood Chest pain Coughing blood Enlarged glands Diarrhoea BOTSWANA NTP 2007 NAMIBIA* NAP 2010 SOUTH AFRICA NAP 2010 Cough UGANDA NTP 2010 Cough Fever Weight loss Night sweats Chest X-ray Sputum smear TST Chest X-ray Sputum smear Cough Fever Night sweats Enlarged lymph nodes Chest pain NIGERIA*** NAP 2010 Chest X-ray Sputum smear Cough Fever Weight loss Enlarged lymph nodes Abnormal chest findings Enlarged glands KENYA OI 2008 NTP 2009 Chest X-ray Cough

1.Botswana and Mozambique – No IPT initiation in pregnancy 2.Botswana and Tanzania – IPT not for children 3.South Africa – IPT with ART is a conditional recommendation 4.Lesotho – IPT offered to TB-exposed HIV infected children and at pilot sites where active TB can be ruled out 5.Malawi – Stop IPT when patient is started on ART 6.Kenya and Swaziland– IPT provided in clinics with TB screening, adherence counselling and patient follow-up services 7.Uganda – IPT provided in institutions with adequate human resources, infrastructure, and equipment and logistics Exceptions to WHO recommendations on IPT 2010 WHO Recommendation : IPT to all irrespective of previous history of TB or current pregnancy and IPT with ART also recommended

Indicators for monitoring and evaluating performance on the Three I’s for HIV/TB ICF YesNo Botswana Kenya South Africa Tanzania Zimbabwe Lesotho Ethiopia Malawi Mozambique Namibia Nigeria Swaziland Uganda Zambia IPT YesNo Kenya Malawi Nigeria Tanzania Zambia Botswana Ethiopia Lesotho Mozambique Namibia South Africa Swaziland Uganda Malawi, Namibia, Nigeria, Swaziland and Uganda have indicators for TB infection control

Limitations  Guidelines may be outdated and/or in the process of being updated  Written policies may not reflect programme implementation  Other guidelines covering ART and the Three I’s for HIV/TB may exist - Infection control guidelines - Monitoring and evaluation guidelines

Conclusion Many countries follow the recently released WHO guidelines - Asymptomatic patients – 8 countries - HIV/TB co-infected people – 7 countries - Pregnant women – 10 countries Malawi recommends lifelong ART for pregnant women irrespective of CD4 count (Option B+) Almost all countries have recommendations on the Three I’s for HIV/TB CPT initiation criteria differs widely across countries ICF and IPT guidelines specified in both NAP and NTP for many countries Many countries have ICF and IPT indicators Room for improving monitoring and evaluating progress on TB infection control

Recommendations ART policy  Revise ART eligibility criteria where necessary IPT policy  Adapt policies to recommend IPT for all, including pregnant women, previous TB patients and PLHIV on ART  Simplify criteria for IPT initiation Monitoring and evaluating of the Three I's for HIV/TB  Include indicators on ICF and IPT in National ART Guidelines  Adapt and implement indicators for TB infection control

Thank you…