1. World Bank, October 5, Tackling TB in the HIV era: implications for policy dialogue and operations
Paul Nunn
5 October 2005

2. " We can’t fight AIDS unless we do much more to fight TB as well "
Nelson Mandela
Bangkok, July 2004

3. Contents Current status of TB and HIV epidemics, focus on Africa
The policy response
Progress and operational issues
Political and partnership commitments
Conclusions

4. Current status of TB and HIV epidemics, focus on Africa

5. TB incidence rate 1990 2005 Stop TB Department No estimate < 50
50-100
300 and more
2005
Stop TB Department

7. Current Global Status 8.8 million new cases of TB in 2003
7.6% of total cases HIV+ ( ) = 12% of adult cases
TB notifications and estimated incidence stable or decreasing in 5 WHO regions, increasing in Africa, due to HIV
Global estimated incidence grew 1%
Global prevalence and mortality rates falling

10. Epidemic in sub-Saharan Africa
1985−2003 5 10 15 20 25 30 5 10 15 20 25 30
Millions
Number of people living with HIV and AIDS
% HIV prevalence, adult (15-49)
% HIV
prevalence
adult (15-49)
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Source: UNAIDS/WHO, 2004
2004 Report on the Global AIDS Epidemic (Fig 5)

11. Nairobi

12. TB Trends in Africa, 1980-2003 HIV driving the TB Epidemic
Global Tuberculosis Control. WHO Report WHO/HTM/TB/

13. TB/HIV in Africa – 2003 Total cases annually in SSA 2.35m
Estimated number (%) HIV + 596k (25%)
Cases notified annually in SSA 996k
Estimated no. of notified HIV+ 243k
% Adult TB patients HIV+ 37%
Deaths from TB due to HIV 207k
% of HIV deaths due to TB 15%
Treatment success 73% (average 82%)

14. Countries ranked by a) Number: the number of TB cases attributable to HIV (thousands) and b) Rate: the number of TB cases attributable to HIV per 100,000 population. Above red line: 80% of total number; above blue line: 90% of total number
Rank Country Number Country Rate Rank Country Number Country Rate
1 S. Africa 77.8 Botswana Rwanda 7.6 C. d'Ivoire 197
2 Ethiopia 59.2 Zimbabwe B. Faso 6.5 Uganda 173
3 Nigeria 49.9 Lesotho Burundi 6.4 Tanzania 155
4 Kenya 43.9 Swaziland Ghana 6.0 Cameroon 147
5 India 41.4 Zambia Thailand 5.6 B. Faso 132
6 Zimbabwe 29.2 Namibia Botswana 5.5 Congo 128
7 Tanzania 25.2 S. Africa CAR 4.9 Cambodia 126
8 DR Congo 22.6 Djibouti Myanmar 4.9 Togo 113
9 Mozam Malawi Lesotho 4.8 DR Congo 105
10 Zambia 18.9 Kenya Haiti 3.7 Nigeria 96
11 Uganda 17.3 CAR Angola 3.1 Haiti 94
12 Malawi 16.1 Mozam Namibia 3.1 Gabon 82
13 C. d'Ivoire 15.0 Burundi China 2.9 Ghana 64
14 Cameroon 10.1 Rwanda Togo 2.4 S. Leone 56
15 Cambodia 7.7 Ethiopia USA 2.3 Angola 56

19. Epidemiological summary
TB coming under control everywhere except Africa (and Eastern Europe)
HIV is the proximal cause in Africa
East and Southern Africa worst hit
Women more affected than men by TB/HIV
Mortality from TB rising with HIV
Most TB in Africa in HIV uninfected
Notwithstanding, TB control nearing 2005 targets
MDGs likely to be met, except in Africa and Eastern Europe
Battleground for TB MDGs shifts towards Africa

20. The policy response

21. WHO-recommended Stop TB Strategy to Reach the 2015 MDGs
Pursuing quality DOTS expansion and enhancement
Political commitment
Case detection through bacteriology
Standardised treatment, with supervision and patient support
Effective drug supply system
Monitoring system and impact evaluation
Additional components from October 2005
2 Addressing TB/HIV and MDR-TB
3. Contributing to health system strengthening
4. Engaging all care providers
5. Empowering patients and communities
6. Enabling and promoting research 14

23. Therefore DOTS alone is insufficient to control TB where HIV is high and rising

24. Additional options: TB/HIV Collaborative Activities
Decrease the burden of tuberculosis in people living with HIV/AIDS
Establish intensified tuberculosis case-finding
Introduce isoniazid preventive therapy
Ensure tuberculosis infection control in health care and congregate settings
Decrease the burden of HIV in tuberculosis patients
Provide HIV testing and counselling
Introduce HIV prevention methods
Introduce co-trimoxazole preventive therapy
Ensure HIV/AIDS care and support
Introduce antiretroviral therapy
Establish mechanisms for collaboration
Set up a coordinating body for TB/HIV activities
Conduct surveillance of HIV prevalence among tuberculosis patients
Carry out joint TB/HIV planning
Conduct monitoring and evaluation

25. TB/HIV policy guidance - 2004
Interim policy M&E Surveillance ART
ProTEST lessons TBHIV Clinical HIV testing
policy

26. Experience from ProTEST, Malawi, South Africa, Zambia etc
TB/HIV collaboration possible and useful
Responds to huge unmet need
Filled a large policy void
Policy makers and managers convinced -> expansion
Involvement of all stakeholders critical
Additional staff essential
Technical support essential
More operational research/cultural understanding required to increase adherence to preventive treatments
Standard monitoring and evaluation tools needed
Joint TB/HIV work sets stage for ARVs

27. Progress and operational issues

30. Global Plan to Stop TB II, 2006-2015 Cost by type of investment
5.5 bn

31. Countries involved Making progress - Africa:
Botswana, Cote d'Ivoire, DRC, Ethiopia, Kenya, Malawi, Rwanda, South Africa, Tanzania, Zambia
Making progress elsewhere:
Brazil, Cambodia, Haiti, India, Thailand, Central America
Starting:
China, Indonesia, Mozambique, Namibia, Nigeria, Uganda, Vietnam

32. Malawi
In year to July 2004, 27% TB patients received HIV test – 67% HIV +ve
Of those positive, 90+% received CPT
Of patients ever started on ART up to July 2005, 3081 (13%) due to TB
Of 5696 patients on ART in Q2 2005, 908 (16%) due to TB – 13% of all TB patients registered in Q2

33. And we have the imperative of peoples lives that can be transformed when they access appropriate care.
I think we have to make HIV testing of TB patients feasible…..
Comprehensive HIV treatment including DOT- TB/ART is feasible even in the poorest of settings (PIH Haiti)

34. TB/HIV Expansion progress – Sept 2004
Funding commitment is no longer the bottleneck
PEPFAR increasing TB/HIV element in 2006 country operational plans – ART targets cannot be met without involving TB programmes
TB/HIV emphasised in GFATM R5 – TB/HIV in:
17/22 approved TB proposals
6/25 approved HIV proposals
TB/HIV activities in most regions
13/33 countries surveyed have coordination mechanism, 50% doing joint planning
Large human resource gap
Recording and reporting gap at peripheral level

35. TB/HIV Diagnosis and Referral
TB Control Program
HIV Control Program
TB Suspect
HIV Suspect
TB Unit
HIV testing centre
No TB
Active TB
HIV Positive
HIV negative
WHat we are discussing here is ensuring that all patients with TB disease are able to access HIV testing and thus the full package of appropriate HIV prevention care and support.
THis is a rather vertical schematic representation of what I am talking about but this is just as likely to occur in the context of an integrated PHC clinic with one nurse managing both TB suspects and HIV suspects as it is to be separate TB and HIV units at some distance from each other. Indeed as we are dealing with 2 disease but often in the same one patient we are encouraging that these services are provided in the same unit to minimise inconvenience to patients.
TB Health Education
DOTS
HIV/AIDS Care
HIV Prevention

36. Which model of integration ?
HIV/AIDS TB
ARV follow-up
One stop service for TB-HIV co-infected
HIV/AIDS
TB + ARV
TB/HIV TB
TB patients
Infectious disease
chronic care unit

37. Political and partnership commitments
Commission for Africa, G8, UN World Summit, African Union
Maputo declaration of TB: an emergency in Africa
Stop TB Partnership "blueprint" for action in Africa and WHO/AFRO lead in planning
TB/HIV Working Group
PEPFAR, GFATM and role for increasing WB MAP collaboration

38. Political and partnership issues
TB is perceived as "just another HIV issue"
TB:HIV cultural differences
Treatment vs prevention
Impact of emphasis on HIV/AIDS treatment
Institutional divides
National TB Programmes, National AIDS Control Programmes, and National AIDS Commissions, CCMs

39. Conclusions WHO TB/HIV collaborative activity policy being implemented
Fast multiplication of activities but demand outstripping supply
Urgent need for monitoring and impact evaluation
Funds OK for now - human resources insufficient
Debate on operational issues and country by country resolution of constraints needed
Advocacy, political support, country assistance and close collaboration needed

41. Mandela urges action to fight TB By Chris Hogg BBC Bangkok
BANGKOK: by Lawrence K. Altman –
Nelson Mandela came to the 15th International AIDS Conference here Thursday to lend his prestige to the battles against tuberculosis and AIDS, two deadly diseases that are intricately linked.
BANGKOK (Reuters) –
The global war on AIDS could be lost if the world ignores tuberculosis, often a "death sentence" for people infected with HIV, former South African president Nelson Mandela said on Thursday.
Mandela sounds alarm on TB "death sentence" in AIDS war
By Darren Schuettler

43. Distribution of PCP, Toxoplasmosis and Tuberculosis in Reported AIDS Cases to MOH (Brazil, )
The occurrence of HIV-related opportunistic infections also deeply declined, at a range of 60 to 80%. As you can see in this slide, the shift in the incidence curve of major opportunistic diseases, like Pneumocystis carinii pneumonia, Toxoplamosis and Tuberculosis have occurred particularly after the availability of HAART.
Marco Victoria, DOH Brazil
Source: MOH, 2002