Implementing harmonized TB/HIV indicators and emerging issues. Christian Gunneberg M.O. STB World Health Organisation, Geneva The 15th Core Group Meeting of the TB/HIV Working Group November 3-4, 2009, Geneva, Switzerland

Monitoring and Evaluation Taskforce Update Revision of TB/HIV indicators and implementation. Data harmonization between partners TB/HIV estimates

Harmonized indicators for the HIV/TB Revised TB/HIV indicator guide Harmonized –WHO, UNAIDS, GLOBAL FUND, & PEPFAR Aligned with WHO generic recording and reporting formats Essential for monitoring of 3 Is New –13 instead of 20 indicators –2 Infection control indicators Launched at Implementers meeting Windhoek June 09

–TB status assessment –TB treatment provision –IPT provision On HIV patient forms On HIV Pre ART & ART Registers On quarterly cross-sectional reporting forms Revision of HIV recording and reporting formats measure TB/HIV indicators

Roll out of the revised WHO HIV Reporting and Recording system WHO HIV Department has started training: –WHO intercountry support teams (HIV and TB focal points) –African Regional Workshop Addis Ababa Oct09 –Western Pacific and South East Asia workshops planned for early next year. Then: Cascade training of country staff by intercountry support teams/regional focal points. Also: first draft of French translation to support Francophone countries is available

Data Harmonisation Progress Issues: –Indicator harmonisation (addressed above) –Multiple reports on same indicators –Timing of reporting –Cross checking of TB and HIV registers

Reporting of IPT provision 2008 (PROVISIONAL DATA) Reporting provision of IPTTB PROGRAMMEUNIVERSAL ACCESS REPORT Botswana12802 Haiti Peru Nigeria Ethiopia1493 Mexico Mozambique Dominican Republic Guyana13289 Total IPT numbers reported Number of Countries reporting99

High TB/HIV Burden Countries Reporting 2007 Many high burden countries are not reporting ART/HIV+ care indicator to all three agencies, and are not reporting consistent numbers. Example: South Africa did not report to NAP direct, and reported number more than 10 times higher to PEPFAR than to NAP via NTP, but the total number of TB case notifications in South Africa was 353,619.

Data reconciliation issues (ii) Time periods and reporting Meeting to discuss TB/HIV data issues 19th November WHO/Pepfar

Way forward Feedback to countries: 2008 data from WHO HIV and TB department sources. (Also incorporating Pepfar data) Nov 19th meeting between WHO TB & HIV Dept and Pepfar to discuss data harmonisation processes at international level. –Should result in joint country level feedback from all agencies to encourage harmonised reporting.

Cross checking of TB and HIV registers

In Cambodia ART provision for TB patients is ~ 20% according to TB programme HIV programme data suggests 90% coverage for all those in need of ART. Real or data quality?

Self-made cross-checking register, created by OD TB supervisor OD TB supervisor use the register to cross-referrence between TB and OI/ART registers Increased ART uptake from (1/ 5) 2 new 3PT 20% in the first quarter 2009 to (9/11) 1 new 5 PT 82% for the first two quarters 2009 HIV ve+ TB patients OI register number HIV testing date, ART start date, etc

TB treatment outcome analysis by HIV status, Q Phnom Penh Patient category by HIV status Treatment Success DefaultedDied Others combined Total Known HIV +ve %13.7% 00.0% % HIV tested positive after TB diagnosis %313.0%14.3% % Others (HIV tested negative or not tested) %41.4%20.7%113.9%283100% Total %82.4%30.9%123.6%333100% Duplicate TB register from 4 ODs in Phnom Penh, for the 1 st qtr of 2008 was entered Total 333 cases, out of which 27 (8.1%) were known HIV +ve Of 306 with unknown HIV status, 255 (83.3%) were tested through VCCT and 23 (9.0% of tested) were newly identified with HIV. Treatment success rate is higher in patients with known HIV +ve at the beginning of TB treatment and comparable with overall treatment success rate. Low treatment success rate (78%) and high default rate (13%) are observed among patients tested +ve for HIV after TB diagnosis. Death rate seems high though the sample size is too small to draw any conclusion. A wealth of TB HIV data from routine registers waiting to be analysed

Way forward: HIV registers and reporting systems need to incorporate TB treatment. Register cross checking –of district level ART and TB registers to improve data quality and patient care quality. Treatment outcome analysis – TB and HIV care registers for assessing and programme management.

WHO revised HIV/TB estimates for 2007 Evidence that prior HIV/TB estimates were too low 1.37 m. estimated incident HIV+ TB cases in % estimated TB deaths in 2007 had HIV (456,000/1.77m) 23% of estimated HIV deaths in 2007 had TB (456,000/2m)

Figure 1.2 Geographical distribution of estimated HIV-positive TB cases, For each country or region, the number of incident TB cases arising in people with HIV is shown as a percentage of the global total of such cases. AFR* is all countries in the WHO African Region except those shown separately; AMR* excludes Brazil; EUR* excludes the Russian Federation; SEAR* excludes India and WPR* excludes China Estimates double but evenly distributed accross regions

Estimated TB rate differential increased

Increasing HIV testing of TB patients in Africa I 21% 28% 39% 8% 3% % est.TB/HIV Countries 11% 14% 61% 11% 3% 491, ,

In Africa 44% of TB is estimated to be HIV related in 5% of the popn HIV + 5% pop HIV - 95% pop In the African Region in 2007 we detected around 40% of TB cases DETECTED (40%) NOT DETECTED HIV test not known HIV test known (37%) and in 2007 tested 37% of these for HIV Increase the proportion tested Increase the proportion detected especially among HIV + detecting 23% of estimated HIV related TB

TB/HIV estimates Revision of the TB/HIV estimates: –Is the outcome of TB/HIV collaborative activities and generation of routine data. –Re emphasises the need for Collaboration (3 Is)

Conclusion Revised HIV indicators gradually being rolled out through cascade training by the HIV department. There are large increases in TB/HIV data from HIV sources. Joint inter agency approaches to countries to harmonise data reported at national level. Need within country mechanisms to cross check registers and ensure national data reporting consistency

Question for discussion Indicators revised, High level of implementation on TB side HIV recording and reporting to include TB/HIV indicators being addressed albeit slowly. Increasing reporting of TB/HIV indicators from HIV programmes Global initiative to encourage harmonisation of the annual country level reporting of indicators to WHO and PEPFAR is underway. What should the TB/HIV working group do to facilitate further harmonised TB/HIV data monitoring and evaluation?