1. Tuberculosis and the President’s Emergency Plan for AIDS Relief
12/9/2018
Tuberculosis and the President’s Emergency Plan for AIDS Relief
Bess Miller
Associate Director, TB/HIV
Global AIDS Program
Centers for Disease Control and Prevention
4th Global TB/HIV Working Group Meeting
20-21 September, 2004
Addis Ababa, Ethiopia

2. Outline of Presentation
The President’s Emergency Plan for AIDS Relief
Who?, What?, Where?
TB/HIV and The President’s Emergency Plan
Where are the linkages?
How will this translate into action at country level?
Operationalizing TB/HIV activities in the context of ARV
Programs
Challenges and Opportunities

3. Collaboration Across the U.S. Government to Fight Global AIDS
12/9/2018
Collaboration Across the U.S. Government to Fight Global AIDS
State Department
Office of the Global AIDS Coordinator (OGAC)
USAID
Embassies
Department of Health and Human Services
CDC
NIH
HRSA
FDA
Departments of Defense, Labor, and Commerce
Peace Corps
The U.S.G response to the epidemic:
Three HHS agencies are currently involved in global HIV/AIDS activities: CDC, which has the lead role for the department; NIH, which sponsors a variety of research with US and international academic institutions; and HRSA, which helps build capacity in treatment and care. HRSA receives approximately $3M from CDC for that effort.
Re: Global Fund – With HHS Secretary Tommy Thompson now the Board Chair, the US government’s role will be more prominent. Already, GAP and USAID staff have worked with host country governments to develop their applications to the Global Fund – many of which were successful in securing funding. NASTAD provided TA to China and Guyana for their Global We will continue working with host countries to provide essential technical assistance and expect NASTAD members will play a role in that. As you know, Global Fund monies come without technical assistance, and we feel strongly that, for programs to have their greatest effect, CDC and USAID staff, as well as other donors and NGOs, will need to provide assistance in program development, implementation and evaluation.

4. The President’s Emergency Plan for AIDS Relief
Announced January 28, 2003
15 focus countries
Goals:
Treat 2 million HIV-infected people
Prevent 7 million new HIV infections
Provide care for 10 million HIV-infected people and AIDS orphans

5. The President’s Emergency Plan for AIDS Relief Three Tiers
Leadership in HIV/AIDS in all countries
Strong bilateral HIV/AIDS programs in ~100 countries
Focused attention in 15 countries

6. The President’s Emergency Plan for AIDS Relief
15 Focus Countries

7. The President’s Emergency Plan for AIDS Relief Implementation
To be implemented as a single USG program coordinated by the Global AIDS Coordinator
Coordinates with other donors at HQ and country level
Works within national plans of countries
To be implemented based on a "network model“ of health care delivery
PLANNING IS DONE AT COUNTRY LEVEL

8. Legislative Mandate for Distribution of The Emergency Plan Funds
Orphans & Vulnerable Children 10%
Prevention 20%
Treatment* 55%
Palliative Care 15%
Overall budget: $15 billion over 5 years
**75% of treatment funds should be for purchase and distribution of ARVs
Source: Public Law

9. Eight of the 15 Focus Countries are Among the 22 high TB Burden Countries.
Ethiopia
Kenya
Mozambique
Nigeria
South Africa
Tanzania
Uganda
Vietnam

10. TB in Emergency Plan Focus Countries
13 of 15 have had large annual increases in TB incidence since 1997
Over 435,000 HIV-infected persons with active TB in the 15 countries
In Namibia, South Africa, and Zambia
>60% of adult TB patients are HIV+
In Botswana
79% of adult TB patients are HIV+

11. How can TB DOTS Programs Contribute to Meeting Goals of the President’s Emergency Plan?
Readily identifiable candidates for ARV therapy
(Treat 2 million…)
Readily identifiable candidates for OI treatment and prevention, including TB
(Provide care for 10 million…)
Model program for developing ARV programs
Sites for routine HIV counseling and testing and referral to HIV care, partner testing (Prevent 7 million…)

12. Priority TB/HIV Activities for PEPFAR Countries -1-
HIV C & T all TB patients
Screen all HIV+ for active TB
Establish referral systems
Improve TB diagnostic capabilities in healthcare facilities and labs serving HIV-infected patients

13. Priority TB/HIV Activities for PEPFAR Countries -2-
Improve adherence to treatment
– Work with AIDS CBO’s, FBO’s, NGO’s
Strengthen TB/HIV surveillance systems
Include IPT for HIV+
Facilitate coordination of TB-HIV collaborative activities

14. Priority TB/HIV Activities for PEPFAR Countries -3-
Implement basic TB infection control policy for settings
caring for both patients with HIV/AIDS and active TB
Cross-train health workers in TB and HIV
Evaluate TB/HIV activities
– TB/HIV referral systems
– TB treatment completion in TB/HIV patients

15. Guidance for HIV Caregivers Managing TB
Starting ARV in TB patients
Contacting the NTP
Screening for TB
Referring and tracking TB patients
Infection control
Preventing MDR TB

16. When to Start ARV in TB Patients
12/9/2018
When to Start ARV in TB Patients
CD4 < 200 mm – Start ARV between weeks and 2 months
CD mm – Start ARV after initiation phase
CD4 > 350 mm – Defer ARV
CD4 unavailable – Start ARV based on clinical evaluation of immune status
For all, timing of ART should be based on clinical judgment in relation to other signs of immunodeficiency
For EP TB, start ART as soon as possible, irrespective of CD4
For cd4>350, would start ART if OTHER conditions of stage IV present
WHO, Scaling Up ARV, 2003 Revision

17. Contacting the NTP Contact NTP when establishing HIV care programs
Report all new cases of TB to NTP
Meet with NTP on a regular basis

18. Screening for TB Develop TB symptom screen questionnaire
Train hcws on administration of questionnaire and on signs/symptoms of TB
Identify convenient site(s) for further TB diagnostic evaluation

19. Referring and Tracking TB Patients
Develop tracking system for patients referred
for TB dx and rx.
Monitor success rates of referrals
Identify TB/HIV coordinator in HIV Care program to
follow up referred TB patients
Meet with NTP on a regular basis

20. Addressing TB Infection Control
Develop TB Infection Control Plan
Identify staff member/team to oversee infection control practices
Develop triage and evaluation plan for suspect TB patients in outpatient settings
Do not treat MDRTB in HIV care setting
Educate health workers and patients
WHO, Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-Limited Settings, 1999

21. in an Outpatient Clinic
Poorly Ventilated Waiting Area
in an Outpatient Clinic

22. Alternative for Waiting Area Maximize Natural Ventilation

23. Preventing MDRTB
“A poor TB control program is worse than no TB control program.”

24. Preventing MDRTB
For patients on TB drugs and ARV, don’t discontinue any TB drugs without evidence of significant side effects.
Never add a single anti-TB drug to a failing TB regimen.
Monitor patients who have been referred for TB treatment closely. Prevent treatment default.
Meet with the NTP on a regular basis.

25. Thank you!