World Health Organization Western Pacific Region From Mekong to Bali: Scale up of HIV/TB Collaborative Activities in Asia Pacific. Key Outcomes What next for Asia? From Mekong to Bali: Scale up of HIV/TB Collaborative Activities in Asia Pacific. Key Outcomes What next for Asia? Massimo N Ghidinelli HSI WPRO The 15 th Core Group Meeting of the TB/HIV Working Group 3-4 November 2009, Chateau de Penthes - Geneva

World Health Organization Western Pacific Region Outline From Mekong (2004) to Bali (2009). Context, objectives, and highlights of TB/HIV regional consultations Progress in implementing collaborative activities Observations and Conclusions

World Health Organization Western Pacific Region From Mekong to Bali: The Scale up of TB/HIV Collaborative Activities in Asia Pacific Region 8-9 August 2009, Bali 127 persons from 18 countries from Asia-Pacific

World Health Organization Western Pacific Region Objectives/Sessions Review progress and lessons learned since 2004 Greater Mekong meeting. Update on regional policy and strategies, review of successful collaborative TB/HIV activities Review successes and challenges and measures to enhance collaboration between TB and HIV programmes, partners, NGOs, businesses, and communities Provide updates on global policies related to TB/HIV management, monitoring and evaluation and to examine developments in local operational research and TB in migrants Breakout session to discuss best practices, identify constraints, and possible solutions to expand TB/HIV scale-up to inform action points for national operational plans on TB/HIV Develop a framework for country specific priorities to accelerate the implementation of TB/HIV activities Develop and strengthen partnerships and increase funding for TB/HIV activities

HIV/AIDS in the Asia Pacific Region  Second highest HIV burden in the world  Estimated 4.9 million people living with HIV/AIDS  >95% burden borne by 9 low and middle-income countries High HIV Burden Countries in Asia Pacific Cambodia, China, India, Indonesia, Myanmar, Nepal, Papua New Guinea, Thailand, Vietnam

World Health Organization Western Pacific Region HIV prevalence in new TB cases (2007) HBC Source: TB Control in the WPR 2009 Report

World Health Organization Western Pacific Region Estimated morbidity and mortality due to TB/HIV co-infection in the Western Pacific Source: Global Tuberculosis Control 2009, WHO, Geneva

HIV seroprevalence among TB cases CountryEstimated HIV seroprevalence among incident TB cases CountryEstimated HIV seroprevalence among incident TB cases Bangladesh< 0.05 %Myanmar10.9% BhutanNot availableNepal2.4% DPR KoreaNot applicableSri Lanka0.2% India~4- 5%Thailand13-24% Indonesia2% -15% (Papua)Timor-Leste<100 cases of HIV reported/yr Maldives<5 cases of HIV reported/yr Source: Tuberculosis Control in the South-East Asia Region, WHO/SEARO, New Delhi, March 2009

ART Scale-up in the Asia Pacific Region:

ART Services in the Asia Pacific Region, 2008 CountryNumber HIV-Infected (% Adult Prevalence) Year ART Program Started Currently Receiving ART Cambodia61,400 (0.90%)200131,999 China700,000 (0.05%)200248,254 India2,300,000 (0.36%) ,237 Indonesia270,000 (0.20%)200510,616 Myanmar240,000 (0.67%)200515,191 Nepal70,000 (0.42%)20042,536 PNG60,000 (1.6%)20045,195 Thailand530,000 (1.4%) ,747 Vietnam280,000 (0.53%)200527,059

World Health Organization Western Pacific Region Mekong Meeting 2004 Rationale HIV fuels TB epidemic & threatens TB control Limited data on HIV/TB co-infection and low awareness Lack of collaboration between NTP and NAP ART scale up (3by5) and role of NTP

World Health Organization Western Pacific Region Outcome of Mekong Conference 127 participants from 11 countries, 5 day meeting Experiences, lessons learned shared: 6 focus countries + partner organizations WHO WPRO TB/HIV framework discussed Country action plans developed & presented (Cambodia, China, Laos, Myanmar, Thailand, Viet Nam)  pilot phase

World Health Organization Western Pacific Region First Regional TB-HIV Framework 2004

World Health Organization Western Pacific Region

World Health Organization Western Pacific Region A revised framework in 2008 to address TB-HIV co-infection in the Western Pacific Region

WHO Policy on TB/HIV + the “4 th I” “Integrated case management” + D. Systems strengthening Establish regular interaction Resource mobilization Capacity building Involve communities, NGOs Strategy for TB- HIV in the SEA Region 3 I’s

World Health Organization Western Pacific Region Policies and Services on TB/HIV in 2008 CountryServices available to screen TB for PLHA IPT for PLHA (policy- guidelines) IPT as part of HIV care Infection control policy for TB in health facilities Brunei Darussalam no yes Cambodia yesno yes China yesnoyes Fiji yesno Lao PDR yesno yes Malaysia yesno yes Mongolia yesno yes Papua New Guinea yes Philippines yesnoyes Singapore yes Viet Nam yesno yes Source: Universal Access Progress Report 2007 and 2008.WHO, UNAUIDS, UNICEF

World Health Organization Western Pacific Region HIV/TB collaborative activities in WPR countries Country No. (%) HIV+ incident TB cases that received treatment for TB and HIV No. (%) newly-enrolled in HIV care given isoniazid preventive therapy (IPT) No. (%) of those enrolled in HIV care who had TB status assessed and recorded during their last visit CambodiaNA (85.7 in 1 site) ChinaNA Fiji1NA02 (100)911 (14) Laos453293NA 131 (71.6)NA Malaysia72 (33.5)30NA 2002 (89.3)1958 (88.0) MongoliaNA000 (0)4 (12.5)10 (26.0) Philippines9 (49.3)129 (46.0)NA PNG (8.0)215 (29.8)47 (2)870 (38.7)1487 (67.0) Viet NamNA Source: Universal Access Progress Reports 2007 and WHO, UNAIDS, UNICEF

World Health Organization Western Pacific Region Reported TB/HIV data (2007) Source: Global TB Control 2009, WHO Geneva All notified TB cases # of TB cases tested for HIV Of which tested +ve for HIV Of HIV +ve, # of cases on CPT Of HIV +ve, # of cases on ARV China1,045,93934,557 (3.3%)1,187 (3.4%) Vietnam98,34414,377 (15%)627 (4.4%)NA Cambodia36,49514,245 (39%)2,922 (21%)1, Malaysia16,91810,082 (60%)1,629 (16%)NA Lao PDR4, (11%)155 (37%)14975

Intensified Case Finding – Screening for TB at ICTCs India, > 8 fold increase in referrals Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies

> 7 fold increase Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies TB Cases Detected through ICF: India 2005–2008

% newly detected PHAs Intensified TB finding among newly detected PLHIV in Thailand, Source: Bureau of Tuberculosis Control, Dept of Disease Control, MopH Thailand, July 2009

TB patients Newly HIV Tested: India > 4 fold increase Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies

IPT Not policy in any country Being piloted in Myanmar and Thailand Commonly heard concerns:  It is difficult to rule out active TB; so we may end up giving monotherapy  INH resistance is high; IPT could further magnify INH resistance.  Managing adherence to IPT is too complicated and would be costly  Not so effective—and IPT efficacy wanes with time

World Health Organization Western Pacific Region Mekong  Bali-Observations Dramatic shift in perceptions on TB/HIV HIV programmes in Asia –begin to implement TB ICF –explore IPT as an extension of ICF for those who are well –recognize IC in HIV care settings requires urgent action –build TB into funding proposals, routine activities, M&E TB programmes in Asia –view TB/HIV as core activity –include HIV data in routine recording/reporting –find and refer co-infected patients to HIV care & ART Both programmes –committed to working together to mitigate dual burden of TB/HIV, and strengthen health systems along the way

World Health Organization Western Pacific Region Bali-Highlights and Conclusions Good progress since Mekong Conference. High level uptake of PITC, ICF varied, low IPT and IC, 4 th I promising Collaboration between NAP and NTP improving, though still insufficient in many countries. Structural corrections? Multi-sectoral developments needed (private sector, Min. of Labour, Unions, Civil society, NGO’s, Faith based organizations)

World Health Organization Western Pacific Region Bali-Conclusions 2 Communities involvement and participation: great potential PLHA  rights based approach, balance heavy medical approach of TB Encouraging examples of extension of TB services into Harm Reduction services for IDU. Issues of stigma Strengthen monitoring functions  better and more reliable data needed by programmes, to sustain advocacy and document achievements. Document good experiences through case studies

World Health Organization Western Pacific Region Bali-Conclusions 3 Engage/include TB services into “linked responses” (HIV/STI/RSH services) Concerns about women’s vulnerability and social exclusion. Include TB services for HIV+ mothers through PMTCT Slow progress of IC efforts. Risk of fragmentation, but opportunity to integrate IC into HSS and submit proposals for funding

World Health Organization Western Pacific Region Bali-Conclusions last Urgent need to improve communication, especially in support of ICF (TB Diagnostic algorithm), and IPT  addressing decision makers, professional bodies-experts, and beneficiaries Investment on operational research, in developing better tools for ICF (diagnostic algorithm) and IPT (cost effectiveness and benefit analysis) Momentum for funding, especially for TB

World Health Organization Western Pacific Region HIV and TB Programmes in Asia Pacific Countries Nani Nair, StopTB SEARO Padmini Srikantiah, HIV SEARO Puneet Dewan, StopTB SEARO Pieter van Maaren, StopTB WPRO Katsunori Osuga, StopTB WPRO Fabio Mesquita, HSI WPRO Teodi Wi, HIS WPRO Nguyen Thuy, HSI WPRO Yu Dongbao, HSI WPRO Acknowledgments