Implementing harmonized TB/HIV indicators and

emerging issues.

Christian Gunneberg M.O. STBWorld Health Organisation, Geneva

The 15th Core Group Meeting of the TB/HIV Working Group November 3-4, 2009, Geneva, Switzerland

Monitoring and EvaluationTaskforce

Update

• Revision of TB/HIV indicators and implementation.

• Data harmonization between partners• TB/HIV estimates

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

Launched at Implementers meetingWindhoek June 09

– 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 measure TB/HIV indicators

Roll out of the revised WHO HIV Reporting and Recording system

• WHO HIV Department has started training:

– WHO intercountry support teams (HIV and TB focal points)– African Regional Workshop Addis Ababa Oct09– Western Pacific and South East Asia workshops planned for

early next year.

• Then: Cascade training of country staff by intercountry support teams/regional focal points.

• Also: first draft of French translation to support Francophone countries is available

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2002

2003

2004

2005

2006

2007

2008

2002 21.8 5.4 2.6 0.0 10.7 1.3 4.4

2003 201.3 28.4 9.2 10.2 1.6 0.3 7.9

2004 168.1 45.7 20.5 9.8 97.4 11.7 12.0

2005 470.1 103.7 58.0 28.9 194.7 35.0 25.9

2006 703.3 193.7 151.5 65.3 314.4 84.7 27.1

2007 1217.2 320.2 197.5 91.0 630.3 91.3 29.2

2008 1361.7 352.1 228.9 108.4 1385.4 161.9 56.1

Tested for HIV HIV-positive CPT ART Screened for TB Diagnosed with TB IPT

Diagnosis and treatment of HIV in TB patientsDiagnosis, treatment and prevention of TB in people with HIV

Collaborative TB/HIV activities, 2002–2008, GLOBAL PROGRESS

Data HarmonisationProgress

• Issues:

– Indicator harmonisation (addressed above)– Multiple reports on same indicators– Timing of reporting– Cross checking of TB and HIV registers

Reporting of IPT provision 2008(PROVISIONAL DATA)

Reporting provision of IPT TB PROGRAMME UNIVERSAL ACCESS REPORT

Botswana 12802 12802

Haiti 7250 2094

Peru 2137 1824

Nigeria 2099 25635

Ethiopia 1493 1493

Mexico 1490 108

Mozambique 724 1394

Dominican Republic 443 848

Guyana 132 89

Total IPT numbers reported 28570 46287

Number of Countries reporting 9 9

High TB/HIV Burden Countries Reporting 2007

• Many high burden countries are not reporting ART/HIV+ care indicator to all three agencies, and are not reporting consistent numbers.

• Example: South Africa did not report to NAP direct, and reported number more than 10 times higher to PEPFAR than to NAP via NTP, but the total number of TB case notifications in South Africa was 353,619.

CountryEst % of global TB/HIV

ART/HIV+ care (NAP via NTP)

ART/HIV+ care (NAP direct)

ART/HIV+ care (PEPFAR)

South Africa 24.4% 15,521 NO DATA 208,800 Nigeria 9.0% 15,418 uncertain data 19,100 India 7.5% 7,130 uncertain data 6,000 Zimbabwe 5.2% NO DATA NO DATA NO DATAKenya 4.6% NO DATA NO DATA 57,900 Ethiopia 4.4% 2,000 2,658 11,600 Tanzania 4.1% NO DATA NO DATA 8,100 Mozambique 3.2% 12,857 5,544 5,900 Zambia 3.1% 6,595 21,103 12,000 Uganda 2.9% 3,566 NO DATA 16,500 TOTALS 68.4% 63,087 29,305 345,900

Data reconciliation issues(ii) Time periods and reporting

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

20072008 2008 data from HIV care and ART registers

Reporting 2009 PEPFAR WHO HIV WHO TB

Data period Publication Which countriesWHO HIV Dep ´2008 Jan - Dec ´Oct 2009 ALLWHO TB Dep ´2008 Jan - Dec ´Dec 2009 ALLPEPFAR ´2007 Oct to Sept 2008 ´Mar 2009 Pepfar supportedGlobal Fund Grant agreement period No publication If grant specifies

Meeting to discuss TB/HIV data issues 19th November WHO/Pepfar

Way forward

• Feedback to countries: 2008 data from WHO HIV and TB department sources.

(Also incorporating Pepfar data)

• Nov 19th meeting between WHO TB & HIV Dept and Pepfar to discuss data harmonisation processes at international level.– Should result in joint country level feedback from all

agencies to encourage harmonised reporting.

Cross checking of TB and HIV registers

• In Cambodia ART provision for TB patients is ~ 20% according to TB programme

• HIV programme data suggests 90% coverage for all those in need of ART.

• Real or data quality?

Self-made cross-checking register, created by OD TB supervisor OD TB supervisor use the register to cross-referrence between TB and OI/ART registers

Increased ART uptake

from (1/ 5) 2 new 3PT 20% in the first quarter 2009

to (9/11) 1 new 5 PT 82% for the first two quarters 2009

HIV ve+ TB

patients

OI register number

HIV testing date, ART start date, etc

TB treatment outcome analysis by HIV status, Q1-2008 Phnom Penh

Patient category by HIV status

Treatment Success

Defaulted DiedOthers

combinedTotal

Known HIV +ve 26 96.3% 1 3.7%  0 0.0% 0 0.0% 27 100%

HIV tested positive after TB diagnosis

18 78.3% 3 13.0% 1 4.3% 1 4.3% 23 100%

Others (HIV tested negative or not tested)

266 94.0% 4 1.4% 2 0.7% 11 3.9% 283 100%

Total 310 93.1% 8 2.4% 3 0.9% 12 3.6% 333 100%

• Duplicate TB register from 4 ODs in Phnom Penh, for the 1st qtr of 2008 was entered• Total 333 cases, out of which 27 (8.1%) were known HIV +ve• Of 306 with unknown HIV status, 255 (83.3%) were tested through VCCT and 23 (9.0% of tested) were

newly identified with HIV. • Treatment success rate is higher in patients with known HIV +ve at the beginning of TB treatment and

comparable with overall treatment success rate. • Low treatment success rate (78%) and high default rate (13%) are observed among patients tested +ve for

HIV after TB diagnosis. Death rate seems high though the sample size is too small to draw any conclusion.

A wealth of TB HIV data from routine registers waiting to be analysed

Way forward:

• HIV registers and reporting systems need to incorporate TB treatment.

• Register cross checking – of district level ART and TB registers to improve data

quality and patient care quality.

• Treatment outcome analysis– TB and HIV care registers for assessing and

programme management.

WHO revised HIV/TB estimates for 2007

• Evidence that prior HIV/TB estimates were too low

• 1.37 m. estimated incident HIV+ TB cases in 2007

• 26% estimated TB deaths in 2007 had HIV (456,000/1.77m)

• 23% of estimated HIV deaths in 2007 had TB (456,000/2m)

Malawi2%

Nigeria9%

South Africa24%

Zimbabwe5%

EUR*1%

India8%

SEAR*3%

China2%

Other21%

Mozambique3%

AFR*13%Côte d'Ivoire

2%Ethiopia

4%

Kenya5%

Uganda3%

UR Tanzania4% Zambia

3%

EMR1%

WPR2%

Russian Federation2%

AMR*1%Brazil

1%

Figure 1.2 Geographical distribution of estimated HIV-positive TB cases, 2007. For each country or region, the number of incident TB cases arising in people with HIV is shown as a percentage of the global total of such cases. AFR* is all countries in the WHO African Region except those shown separately; AMR* excludes Brazil; EUR* excludes the Russian Federation; SEAR* excludes India and WPR* excludes China

Estimates double but evenly distributed accross regions

Estimated TB rate differential increased

Increasing HIV testing of TB patients in Africa

I

21%

28%

39%

8%

3%

% est.TB/HIVCountries

11%

14%

61%

11%

3%

491,755 626,612

2007 2008

In Africa 44% of TB is estimatedto be HIV related in 5% of the popn

HIV +5% pop

HIV -95% pop

In the African Region in 2007we detected around 40% of TB cases

DETECTED (40%)NOTDETECTED

HIV testnot known

HIV testknown (37%)

and in 2007 tested 37% of these for HIV

Increase the proportion

tested

Increase the proportion

detected especially among HIV +

detecting 23% of estimated HIV related TB

TB/HIV estimates

• Revision of the TB/HIV estimates:

– Is the outcome of TB/HIV collaborative activities and generation of routine data.

– Re emphasises the need for Collaboration (3 Is)

Conclusion• Revised HIV indicators gradually being rolled out through

cascade training by the HIV department.

• There are large increases in TB/HIV data from HIV sources.

• Joint inter agency approaches to countries to harmonise data reported at national level.

• Need within country mechanisms to cross check registers and ensure national data reporting consistency

Question for discussion• Indicators revised, • High level of implementation on TB side

• HIV recording and reporting to include TB/HIV indicators being addressed albeit slowly.

• Increasing reporting of TB/HIV indicators from HIV programmes

• Global initiative to encourage harmonisation of the annual country level reporting of indicators to WHO and PEPFAR is underway.

• What should the TB/HIV working group do to facilitate further harmonised TB/HIV data monitoring and evaluation?