1 Irish Forum for Global health 2010 Optimising TB/HIV Programme service delivery through TB/HIV research: The WHO/TDR model. PC Onyebujoh MD, PhD, FRCP (Lond)

2 Irish Forum for Global health 2010 This talk will cover……  Background information on TDR structure and organization  Global TB/HIV epidemiology  TDR TB/HIV Portfolio activities  TDR TB/HIV research model and impact on National Control Programmes  Conclusions and way forward

3 Irish Forum for Global health 2010 Track record Supported >10,000 projects; trained >1,500 PhD scientists Five of 10 tropical diseases targeted for global / regional elimination Mission To develop new and improved tools for tropical disease control To strengthen the research capability of disease endemic countries (DECs) TDR was established as a special programme 30 years ago Key strengths UN’s convening power Location in WHO and links to ministries and control Partner network and brokering capabilities Long-standing DEC relationships Governance structure

4 Irish Forum for Global health 2010 Need for new TDR vision/strategy triggered by critical trends in global research environment DEC's left behind in priority setting Growing regional variation Enhanced research capabilities in DEC's Global research environment for tropical diseases Epidemiological Changes Momentum through new players / initiatives Infectious disease burden remains high Rise in pharmaceutical product development Complexity and fragmentation

5 Irish Forum for Global health 2010 What is Needed? An effective global research effort on infectious diseases of poverty in which disease endemic countries play a pivotal role Extension of TDR Mandate to cover 'infectious diseases of needy populations' Greater social contextualisation of research (including gender issues) bringing closer to control needs

6 Irish Forum for Global health 2010 New TDR Vision To foster: An effective global research effort on infectious diseases of poverty in which disease endemic countries play a pivotal role

7 Irish Forum for Global health 2010 TDR Structure

8 Irish Forum for Global health 2010 Operationalise through Business Lines

9 Irish Forum for Global health 2010 What we want to achieve Innovation Interventions Access

10 Irish Forum for Global health 2010

Estimated number of cases Estimated number of deaths 1.8 million 1.6 – 2.3m 9.4 million (range, 8.9–9.9 m) 0.44 million 0.39 – 0.51m All forms of TB Multidrug-resistant TB (MDR-TB) HIV-associated TB 1.4 million (15%) 1.3 – 1.6 m 0.52 million 0.45 – 0.62m 150, – 0.27m Global burden of TB in 2008

TB/HIV intervention scale-up in Africa Intervention, 2008ActualGlobal Plan % TB patients tested45%68% % HIV+ TB on CPT73%90% HIV+ TB on ART (000s)89279 TB patients tested for HIVHIV+ TB patients on CPT HIV+ TB patients on ART Thousands 31% Thousands Thousands 73%45% 11%

13 Irish Forum for Global health 2010

14 Irish Forum for Global health 2010

15 Irish Forum for Global health 2010

16 Irish Forum for Global health 2010

17 Irish Forum for Global health 2010 The TB/HIV Portfolio (BL 8): Overall Objective  To optimize treatment, case management and delivery of care for all patients' populations with tuberculosis and HIV- infected tuberculosis, including patients with additional co-morbid diseases.

18 Irish Forum for Global health 2010 TDR's TB/HIV Research Portfolio  Specific Objectives –Develop the evidence for shortening and simplification of TB treatment in TB and HIV-infected TB patient populations (Gatifloxacin & 4FDC studies) –Develop the evidence for management of HIV-infected TB patients: –optimal timing & concomitant use of anti-TB and antiretroviral drugs (TB-HAART) –more effective anti-TB chemotherapy regimen for treatment with HAART (Rifabutin) –bio/surrogate markers and ImRx for IRIS and HIV- infected TB. –Strategies for operational implementation of TB and HIV/AIDS case management and Rx in DECs (OR studies)

19 IR/OR Standardized Curricula  Integrating research strengthens the health system, whatever the research findings.  Conducting research close to near normal health service conditions produces results which health services can use immediately; also reduces research costs considerably.  Rigorous research including randomisation is possible when there is a partnership between researchers, health services and patients. Benefits from embedding research in control Progs

20 IR/OR Standardized Curricula  Genuine partnership and trust essential between researchers, health service staff and patients.  Provide opportunity for health service to ask relevant questions.  Keep research simple. Answer few questions to a high quality.  Critical that researchers remain independent and maintain equipoise about the interventions that they evaluating.  Maintain good open communications between researchers, health care staff, patient bodies. Conduct regular meetings to maintain interest and motivation. Lessons learnt in integrating research into programmes

21 IR/OR Standardized Curricula  Test understanding of and adherence to SOPs regularly and rely more on within-job training, drama and role play.  Audit procedures regularly, especially at the beginning.  Analyse data regularly, especially during the first week or so to spot problems, gaps.  Maintain 100% accuracy target on all research data. Have stringent and immediate internal checks on data to prevent errors – e.g. –Check data collected by health service physicians while patient is still in clinic –Re-interview samples of patients about their understanding of consent as they leave the interview room. Quality of data

22 Irish Forum for Global health 2010 Conclusion & Way forward  Scale up programme-relevant research to address health issues within the context of Programatic capacity  Donors and technical partners should work with multi& bilateral agencies to facilitate « prog- embedded research »  Donors and technical agencies should engage more actively with GFATM and recepient countries in supporting TB/HIV control efforts

23 Irish Forum for Global health 2010 Acknowledgement  NPR/TDR Collegues  Prof Shabbar Jaffar, TEG, LSHTM  Dr JB Levin UKMRC, Uganda  Dr Peter Mwaba, PS MOH Zambia  Mr kevin Bellis HLSP/DFID, S.Africa  National TB control Programme managers (Tanzania, Uganda, Zambia &S.Africa)

24 Irish Forum for Global health 2010 Thank You

25 Irish Forum for Global health 2010 TB Data for South Africa 2009 Population 2009 (millions) 50 Estimates of burden * 2009 Number (thousands) Rate (per pop) Mortality (excluding HIV) 26 (14–42) 52 (29–85) Prevalence (incl HIV) 400 (180–650) 808 (362–1 288) Incidence (incl HIV) 490 (400–590) 971 (791–1 169) Incidence (HIV-positive) 280 (230–340) 563 (461–675) Case detection, all forms (%) 74 (61–91) Case notifications 2009 New cases (%) Retreatment cases (%) Smear-positive (41) Relapse (31) Smear-negative (16) Treatment after failure (4) Smear unknown (27) Treatment after default (9) Extrapulmonary (16) Other (56) Other 0 (0) Total new Total retreatment Total < 15 years Total new and relapse (89% of total) Total cases notified

26 Irish Forum for Global health 2010 TB Data for Ireland 2009 Population 2009 (millions) 5 Estimates of burden * 2009 Number (thousands) Rate (per pop) Mortality (excluding HIV) (0.018–0.03) 0.49 (0.4–0.66) Prevalence (incl HIV) 0.47 (0.15–0.8) 10 (3.3–18) Incidence (incl HIV) 0.38 (0.34–0.44) 8.5 (7.6–9.8) Incidence (HIV-positive) (<0.01–0.025) 0.31 (0.14–0.56) Case detection, all forms (%) 89 (77–100) Case notifications 2009 New cases (%) Retreatment cases (%) Smear-positive 95 (29) Relapse 7 (44) Smear-negative 61 (18) Treatment after failure Smear unknown 58 (17) Treatment after default Extrapulmonary 60 (18) Other 9 (56) Other 59 (18) Total new 333 Total retreatment 16 Total < 15 years 15 Total new and relapse 340 (70% of total) Total cases notified 488