1. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia "TB/HIV Monitoring and Evaluation" This talk will introduce the WHO PEPFAR UNAIDS agreed revision of TB/HIV collaborative indicator guide HIV recording and reporting for HIV/TB Christian Gunneberg M.O. STB World Health Organisation, Geneva

2. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia I will address The revision of the TB HIV indicators The case for better integration of TB and HIV monitoring, How collaborative TB HIV activities have led to the revision of global estimates

3. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia 2004 guide to Collaborative TB HIV activities

4. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia Revision of TB/HIV indicators Issues: Original M&E guide 2004 Revision of WHO TB and HIV R&R include TB/HIV data PEPFAR and UNGASS have own indicators Indicator harmonisation needed for countries Global Fund wanted to update their M&E toolkit

5. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia Harmonized indicators for the HIV/TB Revised TB/HIV indicator guide Harmonized –WHO, UNAIDS, GLOBAL FUND, & PEPFAR Aligned with WHO generic recording and reporting formats Essential for monitoring of 3 Is New –13 instead of 20 indicators –2 Infection control indicators

6. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia % HIV STATUS KNOWN TB/HIV CASE DETECTION ART PROVISION CPT PROVISION FREE CONDOMS % HIV +ve % TB/HIV in HIV CARE

7. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia TB STATUS AT LAST VISIT STARTED TB TREATMENT HEALTH WORKERS WITH TB NEWLY ENROLLED ON IPT INFECTION CONTROL PRACTICES CASE DETECTION (UNGASS 6)

8. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia –TB status assessment –TB treatment provision –IPT provision On HIV patient forms On HIV Pre ART & ART Registers On quarterly cross-sectional reporting forms Revision of HIV recording and reporting formats to measure TB/HIV indicators AIMS: report on

9. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia Progress in TB/HIV indicator reporting by HIV programmes in Asia Pacific Western Pacific Region (of 36) South East Asia Region (of 11)

10. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia PRE/ART registers already contain TB tx and IPT columns Adjust to record month year & TB registration numbers Now also to record TB status at monthly/quarterly visits

11. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia Pre-ART register: TB status follow up

12. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia ART Registers TB status at last visit.

13. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia Cross-sectional quarterly report IPT TB SCREENING TB TREATMENT

14. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia The HIV/TB M&E Challenge: Health facility implementation ART services TB treatment and HIV testing services Country Level PLHIV to be on pre ART register & receive HIV care (ICF/IPT/CPT) here

15. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia Routine HIV testing of TB Patients & Revision of the TB/HIV Estimates

16. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia In all types of HIV epidemics, health care providers should recommend HIV testing and counselling as part of the standard of care to: − all adults, adolescents or children who present to health facilities with signs, symptoms or medical conditions that could indicate HIV infection. These include tuberculosis and other conditions specified in the WHO HIV clinical staging system. http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf WHO recommendations 2007:

17. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia No reported activity < 15% 15 to 50% 51 to 75% More than 75% Proportion of TB patients tested for HIV Key 20042005 2006 2007 12% 16% Progress of HIV testing for notified TB patients Global 3% 9%

18. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia No reported activity < 15% 15 to 50% 51 to 75% More than 75% Proportion of TB patients tested for HIV Key 2005 1.9% Progress of HIV testing for notified TB patients Asia Pacific (47) 2006 2007 0.3% 6.0% 3.7% 2004 18 22 27 29 0.2 of 3.1 million notified TB patients were tested in ASIA PACIFIC REGION in 2007

19. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia ASIA PACIFIC 2007 Proportion of TB patients with known HIV status

20. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia HIV testing and treatment, 2007 RegionTB patients tested for HIV, thousands (%) % of tested TB patients HIV + % of identified TB patients on CPT % of identified TB patients on ART AFR492 (37)516629 AMR114 (49)133677* EMR4.2 (1.1)123565* EUR169 (35)2.55216 SEAR122 (5.5)153717 WPR95 (6.6)74528 Global996 (16)306330 Access to ART is very low and showed regional variation

21. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia 64 countries with empirical data in 2007 From national surveys of HIV in TB –7 countries (up from 2 last year) From sentinel surveillance systems –8 countries From routine testing (where tested / new cases greater than 50%) –49 countries (up from 13 last year)

22. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia TB HIV estimates What has changed? Significant upward revision in 2007 HIV-TB estimates: Better direct data –Number of cases double –1.37m incident TBHIV cases in 2007, Previous estimate (2006): 0.7m – Number of deaths double – 23% of estimated HIV deaths in 2007 had TB 456,000 TBHIV deaths / 2m HIV deaths

23. From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia- Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia Conclusion and next steps Collaborative activities have improved surveillance Need to enhance TB HIV M&E –HIV testing of TB patients –TB analysis from HIV registers –e.g. better TB surveillance data from HIV care