1. U. S. Senate Briefing World TB Day Celine Gounder, MD, ScM Center for TB Research, Johns Hopkins University Director for Delivery, CREATE On behalf of the IDSA/HIVMA Center for Global Health Policy

2. Epidemiology 9.4 million new cases of TB in 2008. 1.3 million people died from TB in 2008. TB is the #1 cause of death among HIV- infected persons. 1/3 of AIDS-related deaths are due to TB. Over 2,000 people in Africa die from TB per day.

3. Estimated incidence of TB (per 100,000 population per year) 2008

4. Malawi Funding from USG: – PEPFAR FY 2008: $23.9 million Including support from CDC for laboratory strengthening – USAID FY 2008: $1.3 million – Global Fund disbursements to date for TB, HIV and HSS : $2.8 million for TB $21.3 million for Health Systems Strengthening $248 million for HIV Total $272.1 – U.S. Contributions :1/3 or $81.7 million

5. Community sputum collection points Project Hope sites in Mulanje, Malawi

6. Specimen transport

7. Sputum smear microscopy Scaling up of sputum smear microscopy is supported by USAID’s TB CAP.

8. SWAp: Sector Wide Approaches

9. Information systems and evaluation

10. Baobab Health

11. Reference: World Health Report 2006.

12. Limits to task shifting

13. Doctors trained in sub-Saharan Africa working in OECD countries Reference: World Health Report 2006.

14. TB is a women’s health issue. Reductionist view of women’s health = reproductive and maternal health Tuberculosis is a leading killer of women. – 700,000 women died from TB in 2008. – 536,000 women died from maternal causes in 2005. – Third leading cause of death among women ages 15-44. – Feminization of the HIV epidemic  higher burden of TB in women – More among women than men despite low burden of HIV: Afghanistan Pakistan To better serve women, TB should be integrated with HIV, antenatal, reproductive health, family planning and STI treatment services. References: WHO 2009 Women and TB fact sheet. Maternal mortality in 2005. World Health Organization, Geneva, 2007.

15. Integration of TB with PMTCT in Soweto, South Africa 3,970 pregnant women were screened for TB at ANC clinics between 12/08 to 8/09 36% HIV-infected TB prevalence – HIV-infected: 696 per 100,000 – HIV-uninfected: 200 per 100,000 Reference: Gounder et al. CROI 2010. Session 180, Abstract 900.

16. Global Goals IndicatorStop TB Targets for 2007 Progress by 2007 % of SSM+ TB detected68% for 2007, 78% for 2010 63% % of all TB detected70%56% % SSM+ TB cured85%78% DOTS (23% non-DOTS) # TB cases worldwide (prevalence) 7.8 million by 2015 13.7 million # TB deaths worldwide750,000 by 20151.8 million % TB patients tested for HIV56% for 200716% # TB/HIV patients receiving co-trimoxazole600,000200,000 % TB/HIV patients receiving ART30%34% % HIV patients screened for TB72%2.2% #HIV patients receiving isoniazid preventive therapy1.5 million30,000 Reference: WHO Global TB Control Report 2009. WHO Stop TB. The Global Plan to Stop TB -- 2006-2015. 2006.

17. GHI Consultation Document not Consistent with Lantos-Hyde Targets IndicatorLantos-Hyde Target 2009- 2013 GHI Targets 2009-2014 # new TB patients receiving treatment4.5 million2.6 million # new MDR patients diagnosed, receiving treatment90,00057,200

18. Particularly poor delivery of TB-related interventions by HIV programs TB screening results in earlier detection of TB: – ↓ morbidity and mortality attributable to TB – ↓ duration of infectiousness – ↓ transmission of TB (and thus also part of infection control) Isoniazid preventive therapy – 50-70% reduction in mortality – Reduces risk of TB among both patients receiving and not receiving ART Infection control – Administrative controls: triage, cough hygiene, reduce time spent in health facilities, occupational health – Environmental controls: ventilation, UV germicidal irradiation – Personal protective equipment References: Innes C. CROI TB/HIV Satellite Session. 2/16/2010. Samandari T. CROI TB/HIV Satellite Session. 2/16/2010. Golub JE et al. AIDS. 2009;23:631-6. Golub JE et al. AIDS. 2007;21:1441-8.

19. USG funding for Global HIV/AIDS and TB (millions of dollars) FY 2009 Enacted Obama FY 2010 FY 2010 Enacted Obama FY 2011 % Change FY 2010 to Proposed FY 2011 Requests from Global Health Coalitions IOM Recommendation by 2012 Global AIDS$5,159$5,259$5,359$5,5002.6%$7,250$7,800* Global Fund $600$900$1,050$1,000-4.7%$1,750 USAID TB$163$173$225$2302.2%$650$800 PEPFAR TB-HIV** $150--$160-- CDC TB$143$144 $143-7%$220-- NIH TB$189--$226$215-4.8%$320-- *Combined bilateral Global AIDS and Global Fund spending. Reference : Institute of Medicine. Recommendations for the U.S. Government. May 2009. ** TB-HIV funding portions of PEPFAR, not additional.

20. Thanks to… Sen. Sherrod Brown Sen. Barbara Boxer Sen. Johnny Isakson Sen. Dick Durbin Sen. Robert Casey Sen. Frank Lautenberg Sen. Benjamin Cardin Sen. Kirsten Gillibrand Sen. Edward Kaufman