Strategic Information and the Control of Tuberculosis Brian Williams and Chris Dye TB programme, Monitoring and Evaluation, WHO

Cure Detect Dynamical models 70% 85% DOTS MDGs Ext. pul. Smear + Culture + Incidence Prevalence Programme data Surveys DataEpiProgrammesPolicy 5%p.a.  MDR HIV

Four questions Where should donors invest? If ‘DOTS don’t do it’ what does? What will ARV drugs do for TB? How can we monitor progress?

Estimated TB cases, 2000 Corbett et al. Archives of Internal Medicine 2003

Estimated TB Incidence Rates, to to to 299 < to or more No Estimate per population 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 –10 10–24 25–49 50–99 100– No data

Estimated TB incidence vs HIV prevalence in high burden countries HIV prevalence, adults years Estimated annual TB incidence (per 100K adults, 1999) HIV prevalence increases by 1% TB incidence increases by 26/100k/yr Everyone had HIV, TB incidence would be 3%/yr

Four questions Where should donors invest? If DOTS don’t do it what does? What will ARV drugs do for TB? How can we monitor progress?

Nairobi Mansoer and Kutwa

Nairobi Marum and Chebet

Nairobi 6 yr

DOTS plus… TB preventive therapy (Malawi)? TB mass treatment (South Africa)? Behaviour change (Uganda)? Condoms (Thailand)? ART (Brazil)? Prophylactic ART?

Impact of inteventions on TB cases TB incidence/100k/yr Baseline ARV 80% TLTI (6 m) TLTI (life) ARV 100% TB detect. TB cure HIV incid Base line: CDR = 50% CR = 70% Interventions: 10% increase Year Currie et al. AIDS 2003 PT (6 mo.) PT (life)

Four questions Where should donors invest? If DOTS don’t do it what does? What will ARV drugs do for TB? How can we monitor progress?

Pulmonary TB Disseminated TB Mono Dual Triple therapy TB among AIDS patients in Brazil

Years since HIV infection Relative TB incidence CD4+ cell counts at start of therapy (100s/  l)

Reduction in the life-time risk of TB among HIV positive people Williams & Dye Science

Four questions Where should donors invest? If DOTS don’t do it what does? What will ARV drugs do for TB? How can we monitor progress?

Is TB incidence falling in Morocco? Incidence rate/100,000 population

Four answers TB investment? 22 high burden countries; especially those where AIDS is high. What might work? Find and cure (better DOTS); refer TB patients for ARV; cut HIV transmission. What will ARVs do for TB? Reduce TB in late stage HIV; little impact on overall transmission Monitoring? Draw on unused local programme data, surveys, expertise and knowledge.

Stategic decision making needs... Strategic data Currently national, aggregated data; local disaggregatged data; surveys; etc. Understand the epidemiology Good models to explain and predict; refinements for HIV Test impact Impact of DOTS programmes; investigate context; monitoring part of treatment.