1. TB/HIV Update Central TB Division

2. Estimated HIV prevalence in new TB cases, 2008

3. National estimate – 4.85% of Incident TB cases are HIV positive

4. Proportion of Registered TB patients who are HIV+, 1q10 <1% 1%-4.9% 5%-9.9% >10% Highly Variable!!

5. RNTCP: HIV status among TB patients registered for DOTS 1Q-2Q 2009 Karnataka State District Total TB patient s register ed for DOTS No. known to be tested for HIV (%) Of the number tested for HIV, no. known to be HIV infected (%) Minimum % HIV positive among registered TB patients BAGALKOT 111491382%42346%38% BELGAUM 2544181271%49327%19% BIJAPUR 113579070%34043%30% DHARWAD 93161266%11619%12% GADAG 53033263%5416%10% HAVERI 75057777%6712%9% UTTARA_KANNADA 64635956%5415%8% BIDAR 85664976%6610%8% BELLARY 1528107570%13312%9% GULBARGA 192295950%15216%8% KOPPAL 87775786%13418%15% RAICHUR 1456119382%18716%13% KARNATAKA 341652424671%397716%12% Source: Central TB Division, 2009

6. Treatment outcomes for HIV-positive and HIV-negative TB patients, 2006 cohort The numbers under the bars are the numbers of patients included in the cohort

7. Treatment Outcomes of HIV positive and HIV negative TB patients, 4q08 NSP TB Patients All TB Patients (N=2034) (N=141304)(N=5422)(N=345661)

8. Lawn et al, CROI 2007 After TB diagnosis, delayed ART initiation associated with higher death rates

9. Mortality rate** (95% CI) Early arm 8.28 (6.42 – 10.69) Late arm 13.77 (11.20 – 16.93) ** per 100 person-years CAMELIA STUDY SIGNIFICANT REDUCTION OF MORTALITY IN THE EARLY ARM ANRS 1295/12160 - CIPRA KH001/10425 study

10. Mortality rate** (95% CI) INTEGRA TED 5.4 (3.5-7.9) SEQUEN TIAL 12.1 (8.0-17.7) ** per 100 person-years Karim et al, Durban, SOUTH AFRICA EARLY ART INITIATION SIGNIFICANTLY REDUCES MORTALITY

11. “Nationally, RNTCP should be able to reverse the increases in TB burden due to HIV but, to ensure that TB mortality is reduced by 50% or more by 2015, HIV- infected TB patients should be provided with antiretroviral therapy in addition to the recommended treatment for TB.”

12. Summary: TB-HIV Interaction in India India has the highest burden of TB, and a high burden of HIV in the world Most TB is among persons without HIV; magnitude variable HIV may slow down TB control efforts in India – Particularly efforts to reduce mortality Enormous need for improved TB-HIV programme collaboration

13. Response to TB-HIV

14. The STOP TB Strategy, 2009 Updated language underlined 2006/rev. 2009 1.Pursue high-quality DOTS expansion and enhancement a.Secure political commitment, with adequate and sustained financing b.Ensure early case detection, and diagnosis through quality-assured bacteriology c.Provide standardised treatment with supervision, and patient support d.Ensure effective drug supply and management e.Monitor and evaluate performance and impact 2.Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations a.“Scale–up” collaborative TB/HIV activities b.Scale-up prevention and management of multidrug-resistant TB (MDR-TB) c.Address the needs of TB contacts, and poor and vulnerable populations 3.Contribute to health system strengthening based on primary health care a.Help improve health policies, human resources development, financing, supplies, service delivery and information b.Strengthen infection control in health services, other congregate settings and households c.Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL) d.Adapt approaches from other fields and sectors, and foster action on the social determinants of health 4.Engage all care providers a.Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches b.Promote use of the International Standards for Tuberculosis Care (ISTC) 5.Empower people with TB, and communities through partnership a.Pursue advocacy, communication and social mobilization b.Foster community participation in TB care, prevention and health promotion c.Promote use of the Patients' Charter for Tuberculosis Care 6.Enable and promote research a.Conduct programme-based operational research, and introduce new tools into practice b.Advocate for and participate in research to develop new diagnostics, drugs and vaccines

15. Evolution of TB-HIV collaborative activities in India 2001–First TBHIV “Joint Action Plan” developed; Basic activities in 6 high-HIV burden states 2003- Cross referral piloted in MH and initiated in 6 states 2004–Expanded to 8 additional States 2005–Joint training modules, surveillance 2007–Expanded surveillance, CPT/Routine referral pilot, National Framework for TB/HIV 2008–National Framework revised, all-India implementation begins with Intensified package in 9 states 2009 – National Framework revised, Intensified package scaled up to include 8 more states 2010 – Intensified package launched in 11 states

16. Currently 11 states implementing (TN,AP,KA,MH,PD,GA,MZ,MN,NG,GU,DL) Launched in 7 states (AS,WB,OR,KE,RJ,PN,CH) IN 2009 Rolled out in 11 states in 2010 (HR,UK,HP,JH,CG,TR,ArP,ME,SI,MP,UP) Intensified TB-HIV package - Nationwide coverage by 2012 Implementing Launched (2009) Launched (2010)

17. National TB/HIV Framework 2009…1 All StatesIntensified Package States District and State-Level Coordination mechanisms between NACP and RNTCP Uniform Intensified TB Case Finding at all ICTCs, ART Centres, and Community Care Centres with Line-list and Standard Reporting Training in basic TB/HIV module Additional training on Intensified TB/HIV Package

18. National TB/HIV Framework 2009…2 All StatesIntensified Package States Referral of TB patients for HIV- testing based on HIV risk factors (selective referral) Routine referral of all TB patients for voluntary HIV- counselling and testing (ISTC 14) Linking HIV-infected TB patients to HIV care and support, including CPT & ART Addition: Decentralized CPT (ISTC 15) Core TB/HIV recording and reporting from NACO MIS and RNTCP (PMR) Addition: Expanded TB/HIV recording and reporting (Shared Confidentiality)

19. All TBHIV Training Modules revised

20. A new “TBHIV module for ART centre staff” created Intensified TB case finding at ART centres with standardised R&R Rifabutin use among HIV-infected TB patients receiving Second line ART or Alternative First line ART (containing Protease Inhibitors) approved Infection control guidelines for ART centre setting included ART in HIV-infected TB patients – regimen, timing of initiation, special situations clarified

21. International & National Guidelines for ART in HIV-infected TB patients WHO (2009)NACO (2009) Who is eligible? ALL, regardless of CD4 (strong recommendation, low quality of evidence) ALL Stage 4 (EP-TB, disseminated, miliary) CD4<350 (Pulm) When to start? Start TB treatment first, followed by ART as soon as possible after starting TB treatment. (strong rec, moderate evidence) Start TB treatment first, followed by ART as soon as possible, 2 weeks after starting TB treatment What to start? Use EFV as the NNRTI in patients starting ART while on TB treatment. Use EFV as the NNRTI in all TB patients receiving ART

22. TB/HIV Performance

23. Trends in Number (%) of registered TB patients with known HIV status, 4q08-1q10

24. Proportion of TB patients with known HIV status, States, 1q10

25. Proportion of TB patients with known HIV Status, 1q10 <49.9% 50%-79.9% >80%

26. Proportion of Registered TB patients who are HIV+, 1q10 <1% 1%-4.9% 5%-9.9% >10%

27. Number (%) of HIV+ TB patients receiving CPT during TB treatment, 4q08-2q09 By quarter of TB registration

28. Number (%) of HIV+ TB patients receiving ART during TB treatment, 4q08-2q09 By quarter of TB registration

29. Trends in Number of TB suspects referred from ICTC to RNTCP 2006–2009

30. Trends in TB case detection from ICTC to RNTCP referrals, 2006–2009 (till September )

31. Next Steps – 2010-15 Intensified TB/HIV package - Nationwide coverage by 2012 – Provider-initiated HIV testing for all TB patients – Immediate and accountable linkage of HIV-infected TB patients to NACP for HIV care and treatment Intensified TB case finding and reporting – Consolidation in all HIV care settings Completed clinical and operational research on IPT for TB/HIV with policy decisions Implementation of airborne infection control measures HIV Surveillance among TB suspects at some sentinel sites RCT among HIV-infected TB patients comparing daily v/s intermittent regimens

32. Role of Medical College in TB/HIV collaborative activities Academics – Frequent updates / CMEs for faculty and students – Demonstration of TB/HIV care settings to students Patient Care – Implementation of ICF and IC at ICTCs and ART centres – Implementation of PITC for TB patients and Early ART initiation for HIV-infected TB patients Research – Operational Research and PG Thesis – Funding available under RNTCP Quality Assurance – Part of RNTCP Internal Evaluations and Joint TB/HIV Visits – Peer Pressure on professional colleagues to follow ISTC

33. Thanks.. A dedicated webpage for TB-HIV