The revised TB/HIV indicators and update on the process of harmonization Christian Gunneberg MO WHO The 14th Core Group Meeting of the TB/HIV Working Group November 11-12, 2008, Addis Ababa, Ethiopia

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

Revision of TB/HIV indicators Issues: Original M&E guide 2004 Revision of WHO TB and HIV R&R include TB/HIV data PEPFAR and UNGASS have own indicators Indicator harmonisation needed for countries Global Fund wanted to update their M&E toolkit

Revision of TB/HIV indicators Recommendations: –The task force notes the revision of the TB/HIV indicators currently planned and suggests that these should be in harmony with the current WHO HIV department M&E revisions and should ensure that this revision is able to deliver quality TB /HIV indicator data at national level. – Piloting of locality crosschecking of TB and ART registers between programmes should be encouraged as part of the M&E process.

Revision of TB/HIV indicators Process to revise Pepfar indicators took place with WHO/HIV&TV DEPT/UNAIDS input. (March/May 08) WHO TB/HIV M&E guide revision meeting 9th to 10th September 2008 synchronised with WHO HIV Department M&E meeting Revision of Generic HIV R&R forms

Revision of TB/HIV indicators WHO TB/HIV M&E guide We reduced the number of indicators from 20 to 12 including 2 new ones. % of TB patients screened for HIV during TB treatment TB patients with HIV status( test result) recorded on TB register/ all TB patients registered Of Tested TB patients % found to be HIV positive HIV positive TB patients / TB patients with HIV test result (status) recorded on register. % of PLHIV attending testing and counselling and Tx and care who were screened for TB % in Care (Pre ART /ART registers) who had TB status assessed during their last visit. Of those who were screened for TB symptoms, how many were newly diagnosed TB % in Care (on Pre ART /ART registers) who started TB Tx during last year

New indicators: Case detection indicator for TB/HIV Number of TB patients registered with documented HIV status on TB register who are HIV-positive, expressed as a proportion of HIV positive TB patients estimated to occur countrywide each year. Infection control: health workers with TB: Number of health care staff working in facilities providing care for people living with HIV, who develop TB in one year, expressed as a proportion of the total number of health care staff working in facilities providing care for people living with HIV during that same year

Case detection indicator This indicator & target will be dependent on TB programme performance also TIME FOR TARGET SETTING- 80% CASE DETECTION ?

Revision of TB/HIV indicators Next steps General & web based consultation process: (November to December 2008) Finalise document December 2008 Publish early in 2009

–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 to measure TB/HIV indicators AIMS: report on

Pre-ART register: TB status follow up

Revision of HIV recording and reporting formats to measure TB/HIV indicators Next steps Still undergoing consultation and pilot testing Then will need roll out and scale up.

The HIV M&E Challenge: Health facility implementation ART services TB treatment and HIV testing services Country Level Three I's must happen all over….

Data harmonisation between partners Recommendation: In view of the recent expansion of TB/HIV monitoring and evaluation data sources at global level, there is a need for: –Regular international and national review meeting processes to ensure that TB/HIV data collected is comparable and consistent, accurate, comprehensive and based on the country Ministries of Health data source and reporting cycle. Technical/donor partners should support that process.

Data harmonization between partners HARMONISATION ACHIEVEMENTS: 1TB /HIV indicators (Status assessment/ TB tx start while in HIV care/ IPT provision) all firmly embedded in WHO generic HIV patient cards, Pre ART ART registers, and quarterly cross sectional reporting formats to central level. 2Global Fund revision document has incorporated the revisions suggested by the Monitoring and evaluation guide review committee: 3 Indicators are also in line with the harmonised indicators agreed by Pepfar. i.e WHO PEPFAR & GLOBAL FUND will asking for the same TB/HIV indicator information.

Data harmonization between partners HARMONISATION ACHIEVEMENTS: 4UNAIDS and WHO AIDS department have conducted a reconciliation between their data bases for people on ART starting TB treatment in WHO TB/HIV Global data continues to come in. The 2007 data collected on HIV side (Jan 2007) and by TB side (now) is being compared. 6 TB CAP project approved to look at data collection and harmonisation in 6 countries. (Zambia, Kenya Tanzania, Malawi, Dominican Republic, Cambodia)

Data harmonisation between partners HIV+TB patients. Pepfar 2 to 5 x NTP to WHO equivalent 1/3 rd of all TB notifications needs further exploration. eg data sources (4 countries)

Data Harmonisation Issues How to ensure reconciliation of TB HIV data at country level involving TB & HIV departments and partners. How to roll out the revised HIV recording and reporting formats including the HIV TB indicators.

TB/HIV estimates Recommendations: in light of recent individual country reassessment of TB/HIV estimates based on direct country data, there is an urgent need for a dissemination strategy which should include revision of the global IRR and estimates in time for the June 9th global TB HIV leaders forum (New York. This revision should also re-examine the data now available for burden of death estimates, and should include the provision of estimate confidence intervals. ( Not all in agreement: There is a WHO Global Taskforce on TB impact measurement, one of whose subgroups will be reviewing the TB and TB/HIV estimates - meeting first time in June in Den Haag. Interim global estimate revisions between annual reports are not currently planned by WHO STB and would not be sensible)

TB/HIV estimates Discussed at Global TB impact measurement task force meeting Recommendations: "3 rd meeting 23 to 25 September 2008" Test out "Kenya analysis" in 2-3 other countries –E.g. Tanzania, Malawi, Rwanda Need better sharing of TB and HIV data Need better collection of data needed to estimate TB/HIV burden –HIV testing among TB patients –TB incidence in those on ART –Screening for TB in those with HIV Clearly communicate recommendations to TB/HIV working group

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO All rights reserved Countries testing Tuberculosis Patients for HIV 2007 No reported activity < 15% 15% to 40% 40% to 75% More than 75% Proportion of TB patients tested for HIV Key IS IT TIME FOR TARGET SETTING ? - OVER 80% TESTED ?

Latest data from Global database.. Countries reporting higher TB/HIV We have an additional 8 countries (5 in Africa) reaching the 60% tested threshhold, joining Rwanda Malawi and Kenya) Target?

In these 18 countries the HIV prevalence increase in TB patients among tested v estimated is by a factor of 1.8

TB/HIV case detection indicator A final thought: the case for higher TB/HIV estimates In Africa we are detecting 42% of all estimated TB/HIV cases IN AFRICA around half of TB patients are detected, Only 38 % of these are HIV tested. (i.e. 19% of all estimated TB cases out there) Can it be that amongst these 19% we are detecting 42% of all estimated TB/HIV cases? Or is it more likely to be 19%... less than half…?

TB/HIV estimates Further exploration and discussions with UNAIDS concerning methodological changes (perhaps incorporating ART eligibility) will be explored by TME/WHO Meanwhile the WHO TB Global Report will continue using direct estimation method if data available/ and revise global IRR in line with best available evidence. We expect TB/HIV estimates to be higher in the next Global Tuberculosis report March 2009