1. 5 th DOTS Expansion Working Group Meeting, Paris, October 28, 2004 Tuberculosis and HIV - Future Directions Paul Nunn, Stop TB Dept., WHO, Geneva GLOBAL PARTNERSHIP TO STOP TB

2. Contents Conclusion of 4 th DEWG Meeting, The Hague, 2003 What DOTS Expanders can do for TB/HIV – and what TB/HIV can do for TB control 4 th TB/HIV WG Meeting, Addis Ababa Future directions DISCUSSION

3. 4 th DEWG: Rationale for Joint TB/HIV Activities HIV drives TB incidence and mortality in high HIV prevalence areas

4. Estimated TB incidence vs HIV prevalence 0 200 400 600 800 0.00.10.20.30.4 HIV prevalence, adults 15-49 years Estimated TB incidence (per 100K, 1999)

5. 4 th DEWG: Rationale for Joint TB/HIV Activities HIV drives TB incidence and mortality in high HIV prevalence areas TB significant cause of mortality among HIV/AIDS patients Where HIV is high and rising, DOTS alone is insufficient to control TB Principles of equity demand greater efforts

6. Regional TB incidences

7. Epidemic in sub-Saharan Africa 1985−2003 0 5 10 15 20 25 30 1985198619871988198919901991199219931994199519961997199819992000200120022003 Millions 0 5 10 15 20 25 30 % HIV prevalence adult (15-49) Number of people living with HIV and AIDS % HIV prevalence, adult (15-49) Year Source: UNAIDS/WHO, 2004 2004 Report on the Global AIDS Epidemic (Fig 5)

8. 4 th DEWG: Rationale for Joint TB/HIV Activities HIV drives TB incidence and mortality in high HIV prevalence areas TB significant cause of mortality among HIV/AIDS patients Where HIV is high and rising, DOTS alone is insufficient to control TB Principles of equity demand greater efforts Joint TB/HIV interventions are needed to control HIV- associated TB –With up to 70% TB patients HIV infected, concomitant patient access to both HIV and TB services essential TB control system can be a major partner for ARV delivery and thus for 3 by 5, PEPFAR etc TB/HIV policy endorsed by DEWG

9. Key facts for TB/HIV in Africa Cases annually in SSA2.35m Cases notified annually in SSA996k Estimated no. of notified HIV+243k Number (%) HIV +596k (25%) % Adult TB patients HIV+37% Deaths from TB due to HIV207k % of HIV deaths due to TB15%

10. New imperatives Standard of care Human rights based approach Patient-centred care MDG targets include prevalence and mortality

11. TB/HIV Collaborative Activities 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 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

12. Establish mechanisms for collaboration New policy: 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 Advantages for TB control: Creates a mechanism for cooperation Measures the size of the TB/HIV problem Creates a route towards patient-centred care Enables understanding of extent you are succeeding and the impact you are having

13. Decrease the burden of tuberculosis in people living with HIV/AIDS New policy: Establish intensified tuberculosis case- finding Introduce isoniazid preventive therapy Ensure tuberculosis infection control in health care and congregate settings Advantages for TB control: Increases case detection Prevents TB cases from occurring – lowers case load Prevents transmission in places you are responsible for (primum non nocere)

14. Decrease the burden of HIV in tuberculosis patients New policy: Provide HIV testing and counselling Introduce HIV prevention methods (Introduce co- trimoxazole preventive therapy) Ensure HIV/AIDS care and support Introduce antiretroviral therapy Advantages for TB control: Identifies those in need of HIV care (co- trimoxazole; ARVs; avoid thiacetazone; psycho-social care etc) Limits HIV spread (and hence TB) Reduces morbidity and mortality (MDG targets) and improves TB treatment outcome

15. Experience from ProTEST (Malawi, South Africa, Zambia), Cote d'Ivoire DRC, Rwanda, etc TB/HIV collaboration possible, feasible and useful Responded to huge unmet need Filled a large policy void Policy makers and managers convinced -> expansion Set stage for ARV delivery Lessons include: –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

16. TB control system can be a major partner for ARV delivery scale up and therefore for achieving the goals of –PEPFAR –GFATM –World Bank –UNAIDS –The Millennium Development project –The "3 by 5" Initiative

17. 4 th TB/HIV WG Meeting Theme: "Two diseases- one patient: scaling up prevention and treatment for TB and HIV" Minimum essential set of guidelines prepared Countries moving Monitoring and evaluation system in place and baseline for 2002/2003 Training cascade underway HIV/TB Task Force in WHO Strong partnership Advocacy environment transformed

18. Mandela urges action to fight TB By Chris Hogg BBC Bangkok Mandela sounds alarm on TB "death sentence" in AIDS war By Darren Schuettler 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. 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.

19. Conclusions – 4 th WG Meeting, Addis Significant progress since Montreux Movement good - long way to go HIV activist community engaging Partnership expanding Support for joint TB/HIV activities from –African Union, Ethiopian PM, Director CDC Focus now implementation in countries Strengthen systems to measure progress

20. "…all member states should embrace and scale up implementation of collaborative TB/HIV activities." African Union, Addis Ababa, September 2003

21. Conclusions and recommendations 4 th WG Meeting, Addis - II WG should add its voice to –Concerns about funding flows –Insufficient human resources –Inadequate political commitment –Insufferable debt burden TB is too technical, too public health oriented –Patient centred care needed –HIV testing is gateway to HIV services –Better care for smear negatives, EPTB, especially more rapid diagnosis New tools needed Need to explore harm reduction for IDUs with TB Research priorities should be determined

22. "Our work should be measured by how many people we put on antiretroviral therapy through our TB programs and by how many people we put on anti-TB and IPT through our HIV/AIDS programs in each country". Zackie Achmat, Treatment Action Campaign, Addis Ababa, September 2003

23. Future directions – and needs Country implementation –Technical assistance –Expand evidence base –R5 GFATM –Measure progress (surveillance, M&E) Advocacy at country level –Support alliance with advocates Increase partnership activity –Regional and partners' take-up of TB/HIV New tools –Coordination with countries Funding –Sustainable

24. Issues for discussion How will TB community increase country level implementation? –HIV testing for TB patients –Better diagnosis for smear negative patients –Advocating for standard of care –Psychosocial care –Harm reduction for IDUs