1. Tuberculosis as a core element in comprehensive HIV/AIDS care
Charles Gilks
HIV department, WHO

2. The UNGASS Declaration
55. By 2003 … in an urgent manner make every effort to provide progressively and in a sustainable manner the highest attainable standard of treatment for HIV/AIDS including prevention and treatment of OIs …. ARVs ...
56. By 2005 , develop and make significant progress in implementing comprehensive care strategies ……
TB is the most important OI in HIV
TB must be the core target in this strategy.

4. Current strategies Significant progress in joint TB-HIV activities
Current HIV care strategies aimed at those who know their status and who are able to declare that.
(guidelines for management, OI prevention etc)
Aim with VCT is to increase those who know they are positive as entry point for care.
Similar approaches in TB control to identify cases and enter them into a vertical programme
Assumes survival until active TB declares itself
Significant progress in joint TB-HIV activities

5. Is this approach enough?
In a typical high-burden HIV-TB country:
Majority (90%+) do not know their HIV status
A few know status and are in Care programmes
More know their status but are unsupported
Undiagnosed active TB in the community (? %)
Diagnosed TB cases in treatment programmes
Presentation and survival compromised by HIV

6. The further challenge Sick patient with unknown HIV and TB status
Present to acute medical services
Not seen as a TB issue (undiagnosed)
Not seen as an HIV issue (undiagnosed)
in high-burden countries acute medical services are increasingly stressed ….
? Extent of problem
? What can be done about it

7. Extent of the problem 25% unselected admissions in Nairobi have HIV-TB
TB-HIV in 40% of autopsies in Abidjan
TB deaths in Hlabisa KZN (6 months):
medical wards 123
TB service 51
Is this seen elsewhere?
What can be done?

8. What can be done? Cohort of HIV-positive adults in Entebbe
1400 followed for four years
standard TB detection & case management
132 cases of TB identified
411 deaths recorded
TB cause of death in 27 clients (7%)
Cryptococcus commonest cause of death (23%)

9. Conclusions
Potentially huge additional TB-HIV disease burden which is currently ignored …...
Unclear of extent and what to do
If not addressed TB will continue as biggest killer in HIV (and we fail with UNGASS)
TB is biggest opportunity for immediately improving outcome and survival for HIV-TB
Go for a positive not fatalistic message