TB/HIV Research Priorities in Resource-Limited Settings

Where we are now and some suggestions for where to go

Paul Nunn14-15 February 2005

Contents of Presentation

• Current context– TB and HIV epidemics and overlap– Status of analytical and policy response

• Definitions• Suggested approaches• Conclusions

Current Global Status• 8.8 million new cases in 2003

– 7.6% of total cases HIV+ (674 000) = 12% of adult cases

• TB notifications and estimated incidence decreasing in 5 WHO regions, increasing in Africa

• Global estimated incidence grew 1%• Prevalence and mortality rates falling• 3% of TB cases tested for HIV

Epidemic in sub-Saharan Africa Epidemic in sub-Saharan Africa 19851985−−2003 2003

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1985198619871988198919901991199219931994199519961997199819992000200120022003

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ons

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% HIVprevalence 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)

TB/HIV in Africa – 2002• Total cases annually in SSA 2.35m• Cases notified annually in SSA 996k• Estimated no. of notified HIV+ 243k• Number (%) HIV + 596k (25%)• % Adult TB patients HIV+ 37%• Deaths from TB due to HIV 207k• % of HIV deaths due to TB 15%• Treatment success 73% (average 82%)

Regional TB incidences

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1980 1985 1990 1995 2000

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rest of world

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FSU

TB/HIV policy guidance - 2004

Interim policy M&E Surveillance ART

ProTEST lessons TBHIV Clinical HIV testing policy

Where are we now?• Global consensus around TB/HIV interim policy• As yet, low dissemination of policy• Slow country level implementation of joint

TB/HIV activities– Some technical approaches undefined eg TB/HIV for

IDU– Low awareness of what needs to be done and how– Operating in the context of weak health systems

• Lack of human resources • Competing priorities: DOTS expansion, ARV scale up etc• "Money, money everywhere, but not a drop to spend" etc

Suggested Definitions

TB/HIV research in resource-limited settings:• Research aimed at improving the care of people with

HIV-associated TB in resource limited settings• Research aimed at improving the prevention of HIV-

associated TB• Research within the domain of "TB/HIV" – the additional

things TB programmes and AIDS programmes need to do to address the TB/HIV overlap

• Research aimed at improving TB/HIV control policies (health systems and policy research)

• Research aimed at improving operations of HIV and TB control (operational research or targeted evaluation)

TB/HIV research definition continued• It therefore includes health policy, health

systems and operational research that address TB/HIV;

• And also, new tools development that addresses the particular problems of the coinfected, eg TB diagnostics for those with HIV, ARVs compatible with rifampicin;

• And also clinical trials that answer operational questions in TB/HIV eg when should HIV+ TB patients start ARVs?

TB/HIV research definition concluded• We do not include research that

specifically addresses TB or HIV issues, with no particular reference to the TB/HIV overlap eg development of new drugs for TB, ways of counselling and testing for HIV to decrease HIV transmission, etc

• We have not included basic research, as not being focused on resource-limited settings

• A suggested approach

Three levels of research• Research to answer specific technical questions

eg does cotrimoxazole preventive therapy add protection to ARVs?

• Research to address how technical interventions can alleviate burden of TB/HIV, and how much (health systems research)

• Research to evaluate the whole TB/HIV package – analogous to the multi-country evaluation of IMCI

The rationale for health systems research for TB/HIV• TB/HIV depends strongly on TB and HIV/AIDS

control• TB and HIV/AIDS control severely limited by

weak health systems – and evidence base on health systems is also weak

• Many of the research questions in background papers are about how to implement TB/HIV activities within health systems

• The cross-cutting topics in agenda address the interaction between TB/HIV and health systems

Policy-maker's Questions Lavis J et al. Use of research to inform public policymaking. Lancet 2004;364:1615-21• What is the best solution to the TB/HIV problem?

– What is the overall benefit of implementing the TB/HIV policy package, and how much does it cost, relative to the other interventions we are, or could be doing?

• What are the best ways to implement activities to solve the TB/HIV problem in my health system?– What governance, financial and delivery arrangements are the

most conducive to the effectiveness of the package, in our setting?

• How can I bring about the necessary changes in the health system to implement TB/HIV activities?– What informational, educational and financial (incentive)

approaches are needed to change behaviours to implement the package?

Assessment of the TB/HIV package• We need to demonstrate success/failure

– Whether it can/cannot be implemented (process indicators)– Whether it has/has not impact (impact indicators)– We need to show where it fails, so as to improve it, and avoid

wasting time and resources• We need to do it fast, so that we encourage more rapid

implementation (if we show it works)• Therefore we need to build assessment into

implementation– TB/HIV annual survey of policy and practice– Revision of routine recording and reporting for TB– Additional "targeted evaluation"/operational research– How to record and report "HIV-side" activities?

• Just do it and evaluate, or more formal assessment?

What is expected of us at this meeting? • Develop the agenda of research priorities• Then develop plans for implementation

– Find financial support– Identify teams of countries/researchers able

and willing– Provide technical assistance– Advocate for TB/HIV research

Conclusions• Reaching TB and HIV MDGs depends on improving TB

and HIV control, especially in high HIV areas• Improving control depends on improving health systems• International consensus around 12 point package of

TB/HIV collaborative activities• A way forward:

– Refine the best technical solutions– Define how they fit into complex, under-resourced health

systems– Once we have a list of priorities, we should look ahead to

• funding needs, • human resources,• advocacy