World Bank, October 5, 2005 Tackling TB in the HIV era: implications for policy dialogue and operations Paul Nunn 5 October 2005

" We can’t fight AIDS unless we do much more to fight TB as well " Nelson Mandela Bangkok, July 2004

Contents Current status of TB and HIV epidemics, focus on Africa The policy response Progress and operational issues Political and partnership commitments Conclusions

Current status of TB and HIV epidemics, focus on Africa

TB incidence rate 1990 2005 Stop TB Department No estimate < 50 50-100 100-200 200-300 300 and more 2005 Stop TB Department

Current Global Status 8.8 million new cases of TB in 2003 7.6% of total cases HIV+ (674 000) = 12% of adult cases TB notifications and estimated incidence stable or decreasing in 5 WHO regions, increasing in Africa, due to HIV Global estimated incidence grew 1% Global prevalence and mortality rates falling

Epidemic in sub-Saharan Africa 1985−2003 5 10 15 20 25 30 5 10 15 20 25 30 Millions Number of people living with HIV and AIDS % HIV prevalence, adult (15-49) % HIV prevalence adult (15-49) 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year Source: UNAIDS/WHO, 2004 2004 Report on the Global AIDS Epidemic (Fig 5)

Nairobi

TB Trends in Africa, 1980-2003 HIV driving the TB Epidemic Global Tuberculosis Control. WHO Report 2005. WHO/HTM/TB/2005.349

TB/HIV in Africa – 2003 Total cases annually in SSA 2.35m Estimated number (%) HIV + 596k (25%) Cases notified annually in SSA 996k Estimated no. of notified HIV+ 243k % Adult TB patients HIV+ 37% Deaths from TB due to HIV 207k % of HIV deaths due to TB 15% Treatment success 73% (average 82%)

Countries ranked by a) Number: the number of TB cases attributable to HIV (thousands) and b) Rate: the number of TB cases attributable to HIV per 100,000 population. Above red line: 80% of total number; above blue line: 90% of total number Rank Country Number Country Rate Rank Country Number Country Rate 1 S. Africa 77.8 Botswana 724 16 Rwanda 7.6 C. d'Ivoire 197 2 Ethiopia 59.2 Zimbabwe 501 17 B. Faso 6.5 Uganda 173 3 Nigeria 49.9 Lesotho 492 18 Burundi 6.4 Tanzania 155 4 Kenya 43.9 Swaziland 478 19 Ghana 6.0 Cameroon 147 5 India 41.4 Zambia 409 20 Thailand 5.6 B. Faso 132 6 Zimbabwe 29.2 Namibia 385 21 Botswana 5.5 Congo 128 7 Tanzania 25.2 S. Africa 333 22 CAR 4.9 Cambodia 126 8 DR Congo 22.6 Djibouti 325 23 Myanmar 4.9 Togo 113 9 Mozam. 21.5 Malawi 323 24 Lesotho 4.8 DR Congo 105 10 Zambia 18.9 Kenya 295 25 Haiti 3.7 Nigeria 96 11 Uganda 17.3 CAR 290 26 Angola 3.1 Haiti 94 12 Malawi 16.1 Mozam. 258 27 Namibia 3.1 Gabon 82 13 C. d'Ivoire 15.0 Burundi 228 28 China 2.9 Ghana 64 14 Cameroon 10.1 Rwanda 211 29 Togo 2.4 S. Leone 56 15 Cambodia 7.7 Ethiopia 209 30 USA 2.3 Angola 56

Epidemiological summary TB coming under control everywhere except Africa (and Eastern Europe) HIV is the proximal cause in Africa East and Southern Africa worst hit Women more affected than men by TB/HIV Mortality from TB rising with HIV Most TB in Africa in HIV uninfected Notwithstanding, TB control nearing 2005 targets MDGs likely to be met, except in Africa and Eastern Europe Battleground for TB MDGs shifts towards Africa

The policy response

WHO-recommended Stop TB Strategy to Reach the 2015 MDGs Pursuing quality DOTS expansion and enhancement Political commitment Case detection through bacteriology Standardised treatment, with supervision and patient support Effective drug supply system Monitoring system and impact evaluation Additional components from October 2005 2 Addressing TB/HIV and MDR-TB 3. Contributing to health system strengthening 4. Engaging all care providers 5. Empowering patients and communities 6. Enabling and promoting research 14

Therefore DOTS alone is insufficient to control TB where HIV is high and rising

Additional options: TB/HIV Collaborative Activities Decrease the burden of tuberculosis in people living with HIV/AIDS Establish intensified tuberculosis case-finding Introduce isoniazid preventive therapy Ensure tuberculosis infection control in health care and congregate settings Decrease the burden of HIV in tuberculosis patients Provide HIV testing and counselling Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy Ensure HIV/AIDS care and support Introduce antiretroviral therapy Establish mechanisms for collaboration Set up a coordinating body for TB/HIV activities Conduct surveillance of HIV prevalence among tuberculosis patients Carry out joint TB/HIV planning Conduct monitoring and evaluation

TB/HIV policy guidance - 2004 Interim policy M&E Surveillance ART ProTEST lessons TBHIV Clinical HIV testing policy

Experience from ProTEST, Malawi, South Africa, Zambia etc TB/HIV collaboration possible and useful Responds to huge unmet need Filled a large policy void Policy makers and managers convinced -> expansion Involvement of all stakeholders critical Additional staff essential Technical support essential More operational research/cultural understanding required to increase adherence to preventive treatments Standard monitoring and evaluation tools needed Joint TB/HIV work sets stage for ARVs

Progress and operational issues

Global Plan to Stop TB II, 2006-2015 Cost by type of investment 5.5 bn

Countries involved Making progress - Africa: Botswana, Cote d'Ivoire, DRC, Ethiopia, Kenya, Malawi, Rwanda, South Africa, Tanzania, Zambia Making progress elsewhere: Brazil, Cambodia, Haiti, India, Thailand, Central America Starting: China, Indonesia, Mozambique, Namibia, Nigeria, Uganda, Vietnam

Malawi In year to July 2004, 27% TB patients received HIV test – 67% HIV +ve Of those positive, 90+% received CPT Of 22973 patients ever started on ART up to July 2005, 3081 (13%) due to TB Of 5696 patients on ART in Q2 2005, 908 (16%) due to TB – 13% of all TB patients registered in Q2

And we have the imperative of peoples lives that can be transformed when they access appropriate care. I think we have to make HIV testing of TB patients feasible….. Comprehensive HIV treatment including DOT- TB/ART is feasible even in the poorest of settings (PIH Haiti)

TB/HIV Expansion progress – Sept 2004 Funding commitment is no longer the bottleneck PEPFAR increasing TB/HIV element in 2006 country operational plans – ART targets cannot be met without involving TB programmes TB/HIV emphasised in GFATM R5 – TB/HIV in: 17/22 approved TB proposals 6/25 approved HIV proposals TB/HIV activities in most regions 13/33 countries surveyed have coordination mechanism, 50% doing joint planning Large human resource gap Recording and reporting gap at peripheral level

TB/HIV Diagnosis and Referral TB Control Program HIV Control Program TB Suspect HIV Suspect TB Unit HIV testing centre No TB Active TB HIV Positive HIV negative WHat we are discussing here is ensuring that all patients with TB disease are able to access HIV testing and thus the full package of appropriate HIV prevention care and support. THis is a rather vertical schematic representation of what I am talking about but this is just as likely to occur in the context of an integrated PHC clinic with one nurse managing both TB suspects and HIV suspects as it is to be separate TB and HIV units at some distance from each other. Indeed as we are dealing with 2 disease but often in the same one patient we are encouraging that these services are provided in the same unit to minimise inconvenience to patients. TB Health Education DOTS HIV/AIDS Care HIV Prevention

Which model of integration ? HIV/AIDS TB ARV follow-up One stop service for TB-HIV co-infected HIV/AIDS TB + ARV TB/HIV TB TB patients Infectious disease chronic care unit

Political and partnership commitments Commission for Africa, G8, UN World Summit, African Union Maputo declaration of TB: an emergency in Africa Stop TB Partnership "blueprint" for action in Africa and WHO/AFRO lead in planning TB/HIV Working Group PEPFAR, GFATM and role for increasing WB MAP collaboration

Political and partnership issues TB is perceived as "just another HIV issue" TB:HIV cultural differences Treatment vs prevention Impact of emphasis on HIV/AIDS treatment Institutional divides National TB Programmes, National AIDS Control Programmes, and National AIDS Commissions, CCMs

Conclusions WHO TB/HIV collaborative activity policy being implemented Fast multiplication of activities but demand outstripping supply Urgent need for monitoring and impact evaluation Funds OK for now - human resources insufficient Debate on operational issues and country by country resolution of constraints needed Advocacy, political support, country assistance and close collaboration needed

Mandela urges action to fight TB By Chris Hogg BBC Bangkok BANGKOK: by Lawrence K. Altman – Nelson Mandela came to the 15th International AIDS Conference here Thursday to lend his prestige to the battles against tuberculosis and AIDS, two deadly diseases that are intricately linked. BANGKOK (Reuters) – The global war on AIDS could be lost if the world ignores tuberculosis, often a "death sentence" for people infected with HIV, former South African president Nelson Mandela said on Thursday. Mandela sounds alarm on TB "death sentence" in AIDS war By Darren Schuettler

Distribution of PCP, Toxoplasmosis and Tuberculosis in Reported AIDS Cases to MOH (Brazil, 1981-2001) The occurrence of HIV-related opportunistic infections also deeply declined, at a range of 60 to 80%. As you can see in this slide, the shift in the incidence curve of major opportunistic diseases, like Pneumocystis carinii pneumonia, Toxoplamosis and Tuberculosis have occurred particularly after the availability of HAART. Marco Victoria, DOH Brazil Source: MOH, 2002