1. PRIORITIZING TB in 2018 PEPFAR COPS
Erica Lessem
Treatment Action Group
January 2018

2. TB/HIV Statistics
People with HIV are 21 times more likely to develop TB
There were 10.4 million new cases of TB worldwide in 2016, of which 1.03 million cases arose in people with HIV
TB is the number one killer of people with HIV
23% of HIV deaths were due to TB disease
However, with care, TB/HIV co-infection is manageable and allows for long, healthy lives
Number of deaths worldwide in 2016, according to the 2017 WHO Global TB Report and 2017 UNAIDS Factsheet
Concept courtesy of ACTION
TB/HIV

3. TB/HIV Global Burden of Disease
Countries with the highest burden of TB/HIV co-infection*:
*The HBC list is defined as the top 20 countries in terms of absolute number of incident cases and the top 10 countries with the most severe burden in terms of incidence rates per capita not captured by the top 20 and meet a minimum threshold of the absolute number of incident cases (1,000 per year for TB/HIV).
TB/HIV
Source:

4. Integrating the TB/HIV response to improve care

5. COPS Priorities

6. Screening & diagnosis (1)
TB and HIV testing is widely available, and free of charge, including:
HIV testing offered to all patients diagnosed with TB
TB testing using Xpert MTB/RIF Ultra offered to all patients diagnosed with HIV
TB screening integrated into primary health care and ANC clinics
for all newly diagnosed PLHIV, including with chest x-ray (digital)
symptom screens at every visit
TB-LAM testing for all presenting to health care with AIDS (advanced HIV or CD4<100 cells/mm3) or danger signs
operational research to use at CD4<200 cells/mm3
Not so fun fact: <55% of PEPFAR supported PLHIV on ART (6.8ml out of the 12.6ml) were screened for TB in 2017
For more information on the Global Plan to End TB :
ADVOCACY

7. Screening & diagnosis (2)
Ensure linkage to treatment
Establish / strengthen specimen transport systems to improve access to lab services and efficient return of results
Laboratory capacity strengthened, including full TB drug susceptibility testing
i.e. liquid culture and first- and second-line line probe assays
For more information on the Global Plan to End TB :
ADVOCACY

8. Prevention (1 of 2)
TB preventive therapy for all PLHIV without active TB disease, and other prevention measures including:
Immediate ART start for people with newly diagnosed HIV
Temprano study (2015): starting ART immediately reduced risk of death and serious HIV related illnesses, including TB, by 44%.
Preventive therapy offered and in regular supply using recommended regimens:
6 or 9 months of daily isoniazid + B6, now available with cotrimoxazole;
3 months of weekly isoniazid plus rifapentine, and B6;
3 or 4 months of daily isoniazid plus rifampicin, and B6;
3 or 4 months of daily rifampicin alone
For more information on the Global Plan to End TB :
Source: Danel C, Gabillard D, Carrou JL, et al. Early ART and IPT in HIV-infected African adults with high CD4 count (Temprano trial). Paper presented at: 22nd Conference on Retroviruses and Opportunistic Infections; 2015 February 23–26; Seattle, WA.

9. Prevention (2 of 2)
Infection control, including properly designed facilities, N95 respirators for healthcare workers, and information for patients and caregivers about preventing the spread of TB
Contact tracing and active case finding
Routine screening for all, especially high-risk populations (e.g. children, prisoners, miners, women presenting to antenatal clinics, etc.)
Not so fun fact: Out of 5M who screened negative for TB in 2017, only 637,000 (~13%) started TB preventive therapy
For more information on the Global Plan to End TB :
ADVOCACY

10. Treatment (1 of 2)
Timely and free treatment for all people with TB diagnosed with HIV, and all people with HIV diagnosed with TB, with medicines in regular supply, including:
Early universal ART for all people with TB diagnosed with HIV
People with CD4 counts <50 cells/mm3 should start ART after 2 weeks
people with CD4 >50 cells/mm3 or people with TB meningitis should start ART after 8-12 weeks
This is to avoid IRIS, which is still unfortunately common in TB/HIV co-infected people
TB treatment for all people with HIV with TB (confirmed or in need of empirical treatment)
based on drug susceptibility results
using daily fixed-dose combinations for adults and children with drug-sensitive TB
For more information on the Global Plan to End TB :
ADVOCACY

11. Treatment (2 of 2)
Person-centered care delivery in an environment conducive to patient needs and treatment success including:
counseling for both HIV and TB
integrated TB/HIV care delivery
accessible clinic hours and/or community-based care
access to transportation support
Management of drug-drug interactions, including through dose adjustments (and potentially rifabutin as necessary)
Medicines and supplements to support treatment
nutritional support for those who need it
anti-emetics, anti-pain medicines, and vitamin B6 (pyridoxine)
Side effect risk assessment and monitoring at baseline and regularly once on treatment
Task shifting to community health workers
Integrated supply chain management for TB and HIV supplies
For more information on the Global Plan to End TB :

12. INTEGRATIVE TOOLS
Diagnostics that can work on both HIV and TB, or work well in people with TB/HIV, can help forge integration:
GeneXpert contains a cartridge for detection of TB (MTB/RIF Ultra) and a cartridge for detection of HIV viral load and early infant diagnosis, as well as other diagnostic cartridges
Centralized high throughput assays can be used to test for TB drug susceptibility as well as viral loading testing, such assays include Abbott’s Real Time Platform
LAM test is a point-of-care diagnostic tool, which is able to test for TB in people living with HIV who have CD4 levels <100 cells/m3 or who are very sick
Preventive therapy, recommended in all people with HIV without TB, also offers a path for integration:
e.g. fixed dose formulation of isoniazid/co-trimoxazole/B6
For other regimens see slide 8
INTEGRATION

13. With thanks to Sevim Ahmedov, Bill Coggin, Mark Harrington for sharing their technical expertise (views here are my own, not theirs) Thanks to the TAG TB team for their development of an earlier iteration of this checklist