1. Strategic Information and the Control of Tuberculosis Brian Williams and Chris Dye TB programme, Monitoring and Evaluation, WHO

2. Cure Detect Dynamical models 70% 85% DOTS MDGs Ext. pul. Smear + Culture + Incidence Prevalence Programme data Surveys DataEpiProgrammesPolicy 5%p.a.  MDR HIV

3. Four questions Where should donors invest? If ‘DOTS don’t do it’ what does? What will ARV drugs do for TB? How can we monitor progress?

4. Estimated TB cases, 2000 Corbett et al. Archives of Internal Medicine 2003

5. Estimated TB Incidence Rates, 2000 25 to 49 50 to 99 100 to 299 < 10 10 to 24 300 or more No Estimate per 100 000 population The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2001 0–10 10–24 25–49 50–99 100–299 300+ No data

6. Estimated TB incidence vs HIV prevalence in high burden countries 0 400 800 1200 1600 0.00.10.20.30.4 HIV prevalence, adults 15-49 years Estimated annual TB incidence (per 100K adults, 1999) HIV prevalence increases by 1% TB incidence increases by 26/100k/yr Everyone had HIV, TB incidence would be 3%/yr

7. Four questions Where should donors invest? If DOTS don’t do it what does? What will ARV drugs do for TB? How can we monitor progress?

8. Nairobi Mansoer and Kutwa

9. Nairobi Marum and Chebet

10. Nairobi 6 yr

11. DOTS plus… TB preventive therapy (Malawi)? TB mass treatment (South Africa)? Behaviour change (Uganda)? Condoms (Thailand)? ART (Brazil)? Prophylactic ART?

12. Impact of inteventions on TB cases TB incidence/100k/yr 800 600 400 200 0. Baseline ARV 80% TLTI (6 m) TLTI (life) ARV 100% TB detect. TB cure HIV incid Base line: CDR = 50% CR = 70% Interventions: 10% increase 1980 2000 2020 2040 Year Currie et al. AIDS 2003 PT (6 mo.) PT (life)

13. Four questions Where should donors invest? If DOTS don’t do it what does? What will ARV drugs do for TB? How can we monitor progress?

14. Pulmonary TB Disseminated TB Mono Dual Triple therapy TB among AIDS patients in Brazil www.aids.gov.br/boletim/bol_htm/boletim.htm

15. Years since HIV infection Relative TB incidence 800 700 600 500 400 300 200 100 0 CD4+ cell counts at start of therapy (100s/  l)

16. Reduction in the life-time risk of TB among HIV positive people Williams & Dye Science

17. Four questions Where should donors invest? If DOTS don’t do it what does? What will ARV drugs do for TB? How can we monitor progress?

18. Is TB incidence falling in Morocco? 0 10 20 30 40 50 60 70 19801985199019952000200520102015 Incidence rate/100,000 population

22. Four answers TB investment? 22 high burden countries; especially those where AIDS is high. What might work? Find and cure (better DOTS); refer TB patients for ARV; cut HIV transmission. What will ARVs do for TB? Reduce TB in late stage HIV; little impact on overall transmission Monitoring? Draw on unused local programme data, surveys, expertise and knowledge.

23. Stategic decision making needs... Strategic data Currently national, aggregated data; local disaggregatged data; surveys; etc. Understand the epidemiology Good models to explain and predict; refinements for HIV Test impact Impact of DOTS programmes; investigate context; monitoring part of treatment.