1. Paul Nunn, STOP TB WHO, Geneva
The 2nd Meeting of the Global Working Group on TB/HIV Durban, June 14-16, Progress
Paul Nunn, STOP TB
WHO, Geneva

2. Contents Summary of the state of the epidemic
Recommendations and practical results
Review of the environment
Future directions

3. Africa: HIV is driving the TB Epidemic TB Notification Rates, 1980-199950
100
150
200
1980
1985
1990
1995
2000
250
300
350
400
450
500
Zimbabwe
Malawi
Tanzania
Côte d'Ivoire
Kenya
Years
Rate (x100,000)
World Health Organization

4. Summary HIV/TB - 2000 L Corbett et al. Arch. Int. Med. In press. 2002
Africa below the Sahara holds nearly one fourth of the world’s incident TB, and this is rising at >3% p.a.
However it contains >80% of the world’s HIV associated TB burden. Over 50% of the half a million deaths occurring with TB in Africa are in the HIV infected.
Around 12% of all HIV/AIDS related deaths are due to TB
L Corbett et al. Arch. Int. Med. In press. 2002

5. Countries ranked by the estimated number of TB cases attributable to HIV (thousands) - 2000
Above red line: 80% of total number; above black line: 90% of total number
Rank Country Number Rank Country Number
1 S. Africa Rwanda 7.6
2 Ethiopia B. Faso 6.5
3 Nigeria Burundi 6.4
4 Kenya Ghana 6.0
5 India Thailand 5.6
6 Zimbabwe Botswana 5.5
7 Tanzania CAR 4.9
8 DR Congo Myanmar 4.9
9 Mozam Lesotho 4.8
10 Zambia Haiti 3.7
11 Uganda Angola 3.1
12 Malawi Namibia 3.1
13 C. d'Ivoire China 2.9
14 Cameroon Togo 2.4
15 Cambodia USA 2.3
Brian Williams kindly prepared this slide for me which summarises the burden of HIV associated TB and ranks it by country. The approach is analagous to that that defines the 22 highest burden countries with TB. Africa once again stands out as the focus of this problem - India is listed at No. 5 because of its huge population, and is the only non-African country in the top 14. Cambodia is the worst-affected Asian country after India, followed by Thailand and Myanmar. Haiti is the highest ranked country in the Americas.
There are alternative ways of presenting this kind of data, and these will be addressed In Brian Williams’ presentation on Sunday.

6. THE FORM of the Global TB/HIV WG Stop TB Governance Structure
New TB
Drugs
TB/HIV
DOTS-Plus
MDR-TB
Diagnostics
DOTS
expansion
W O R K I N G G R O U P S
Vaccines
Stop TB Partners’ Forum
Global TB Drug Facility
Coordinating Board
Partnership Secretariat
WHO Technical
Advisory Group
Cross-cutting issues: Advocacy & Communications/ Financing

7. Recommendations of WG - 2001
Policy development
Finish WHO/UNAIDS Strategic Framework
WG partners to promote national TB/HIV activities
District-level phased implementation of joint TB & HIV/AIDS programme activities
Prepare operational guidelines
WG partners to enhance TB and HIV/AIDS collaboration at international level
Continued support for ProTEST
Identify other TB/HIV joint activities
GA and WHA resolutions
Mobilise resources

8. Recommendations 2001 Develop 5 year workplan
WG partners to promote and support research
2nd meeting of WG to review progress in implementation of recommendations and setting future direction

9. Policy Development Strategic framework
Analysis of interaction between TB and HIV/AIDS programmes in sub-Saharan Africa
Report of the First WG meeting
Distributed
4th World Congress
Barcelona AIDS Conference
Media
UNAIDS and WHO lists
Work in progress:
Mathematical modelling of impact of interventions
Review of the epidemic of TB and HIV and implications
Review of the impact of HIV on recurrence and relapse of TB and recommendations for policy

10. Promotion of National TB/HIV Activities
Phased implementation of district level joint TB & HIV/AIDS activities
Nairobi workshop, February (AFRO,CDC-GAP,USAID)
Country support, Ethiopia, Kenya, Zambia, Mozambique, Tanzania
Mentors
WHO staff
Evaluation of ProTEST
Behavioural
Cost-effectiveness
Operational guidelines for national and district use
Development of standardised data collection instruments
Review of proposals by Scientific Panel of WG, July
Review and completion of operational guidelines by SP
Partner support, eg
CDC-GAP (Zambia)
USAID (Ethiopia)
WHO
“Brokerage” of support, eg
GFATM
World Bank

11. Enhancement of TB and HIV/AIDS collaboration at international level
Expanding collaboration within WHO HQ
TB focal points
Joint staff
Joint approach to country support, GFATM & WG
GA and WHA resolutions
Failed
Continued support for ProTEST
Identification of other TB/HIV joint activities
Establishment of WG core group
Work in progress
Mobilise resources
Database
Assistance with GFATM proposals

12. And... Promotion and support of research
Working paper in preparation on priorities
Development of a 5 year workplan
Planned
Organisation of 2nd Global TB/HIV WG meeting
Review of progress in implementation of recommendations
Future direction of activities

13. External environment Key Happenings: Implications:
Commission for Macroeconomics and Health
GFATM
?3 TB/HIV projects supported
World Bank, HIPC and PRSP
Shift in HIV community to “care” and hence openness to TB
Shift in TB community to address HIV as driving force of TB epidemic
Implications:
Financial resources need not be rate-limiting
Countries are in the driving seat
Demand for high quality technical support remains
Human resources are key bottleneck

14. Future Directions - Recommendations
Continued focus on country support
Close collaboration with HIV/AIDS community
Close collaboration with DOTS Expansion WG
Continue to build evidence for joint TB & HIV programme activities
Focus WG’s global efforts on 25 countries with 90% of the TB/HIV burden
Approach Nigeria and Zimbabwe
Continue with plan for francophone workshop
Consider India and other large countries
Work with RO’s on countries outside Africa
Continue to seek financial resources
Start to address human resource constraints

15. Ways of Working - Recommendations
Improve terms of reference of WG
Strengthen core group and focus on strategic direction of WG
Strengthen partnership
Increase human resources
Address financial resources

16. Work-plan of partners Agreement on technical strategy
Agreement on geographic focus - for debate
Country level plans - begun, requires further planning
What, how, by whom, when?
Costing
Identification of sources of support - begun, requires further work
for WG activities
for technical support, co-ordination
for implementation
Financial gaps - to be defined

17. “There is a tide in the affairs of men, Which, if taken at the flood, leads on to fortune; …..On such a full sea are we now afloat; And we must take the current when it serves, or lose our ventures.”
W. Shakespeare (Julius Caesar)

18. Acknowledgements
Dermot Maher, Philip Onyebujoh, Fabio Scano, Brian Williams
Elyse Kingery, Zahra Ali-Piazza, Nellie Courcoulas, Linda Clemensson
Charlie Gilks, Massimo Ghidinelli, Bernhard Schwartlander
Vainess Mfungwe, Wilfred Nkhoma, Eugene Nyarko
Leo Blanc, JW Lee, Mario Raviglione
Patrick Bertrand
Petra Heitkamp, Michael Luhan