tb-hiv in the south-east asia region 13 th core group meeting of the tb/hiv working group april...

TB-HIV in the South-East Asia Region

13th Core Group Meeting of the TB/HIV Working GroupApril 17-18 New York, USA

Dr Nani Nair Regional Advisor-TB

TB and HIV in South-East AsiaOutlineEpidemiology of TB and HIVContext, issues and concernsThe ResponseFuture steps

But most of worlds TB cases are in the SEA RegionThe Burden:

5 million TB cases 3 million new cases/ year 500 000 TB deaths/ year 4 million people with HIV/AIDS Multi-drug resistance: 2.8% among new cases 18.8% among previously treated casesSource: Tuberculosis in the South-East Asia Region, WHO/SEARO, March 2008

Chart3

1154428

175100

240146

163167

1602810

1097378

2004

Sheet1

Fig 1

251908

BAN

BHU

KRD

IND

INO

MAV

MMR

NEP

SRL

THA

TLS

Sheet1

0.05200.0520

0.0770.70.0770.7

0.130.13

0.170.17

0.260.26

0.350.35

0.450.45

0.57410.5741

0.64213122980.6421312298

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate

Fig. 1: Progress in population coverage andDOTS case detectionSEA Region, 1997-2005

Sheet2

1154428

175100

240146

163167

1602810

1097378

2004

Sheet3

9925

10226

8925

8626

9632

9233

9036

9438

9642

10649

10851

All TB cases (rate)

New ss+ (rate)

Fig. 3: TB notifications (all cases and new smear-positive cases)SEA Region, 1995-2005

0.010.11

0.040.16

0.050.18

0.080.21

0.130.24

0.180.28

0.270.32

0.350.37

0.440.45

0.570.53

0.642005

SEAR

Global

Fig. 4: Case-detection ratesSEA Region, 1995-2005

1304828

254601

107997

123118

51266

50474

51696

2005

Fig.5: Distribution of all notified TB casesSouth-East Asia Region, 2005

86.811637122659.8271072189

149.756478417745.804364799

189.718961223879.1355389541

104.667151846545.9366795031

114.283085182371.2089451075

37.082066869320.0607902736

211.819315505172.331202122

123.274241698353.8716691851

44.656028539723.33799354

79.812557408241.1579717591

397.7824709609109.2925026399

107.618770240951.4780193094

398

All cases

New ss+

cases per 100 000 population

Fig. 6: Notification Rate, New Smear-Positive CasesSEA Region, 2005

0.2554748902

0.2535902967

0.2823440524

0.2987949565

0.3287086359

0.3606582531

0.3973712664

0.4084717167

0.4333808872

0.4841397368

0.5061169292

Positivity rate

Fig. 7: Evolution of smear-positivity rate

63853

75696

19670

93622

240640

585185

851981

DOTS

Fig. 8: Notified cases by treatment categoriesSEA Region, 2005

0.5873201544

1.3189365059

1.5743244127

2.2669172233

2.8466053088

3.056448939

3.6247899496

m:f ratio

age group

Fig 9: M:F ratio among new smear-positive cases per age groupSEA Region, 2005 notifications

50218549

9445371613

12030276415

12184053747

10670537485

7374624128

4529912497

male

female

Age group

Number of cases

Fig. 10: Distribution of cases per age and sex groupNew ss+ cases, SEA Region, 2005

0.6580.062

0.660.06

0.680.06

0.770.06

0.80.05

0.810.05

0.820.03

0.830.04

0.5870.077

0.610.11

0.560.14

0.570.14

0.650.04

0.680.04

0.660.05

0.520.22

New cases

Retreatment cases

cured

completed

Figure 11: Treatment success ratesSEA Region, 1997-2004 cohorts

0.88474176160.01175551090.03828117520.0070022650.02783360450.0303856828

0.7840.05066666670.04533333330.00266666670.01866666670.0986666667

0.83516424050.05287082630.02115915360.03365983010.0292764760.0278694735

0.83870011470.02272307410.04417015020.0239539610.06640559550.0040471045

0.81324381110.08206635090.02539133670.01145905210.05043378480.0174056644

0.954545454500.0303030303000.0151515152

0.75284661750.08295856860.05501865850.02216693780.06209932060.024909897

0.85951827020.01519091280.05309976730.0175174490.02894484740.0257287533

0.83579429740.01654786150.0493890020.00585539710.08223014260.0101832994

0.64906231310.03444636010.07508532420.01498891660.05587417750.1705429084

0.6650.1330.0470.0060.0910.058

0.82753111150.03560361070.04172860720.0199846710.05835492150.0167970782

cured

completed

died

failure

defaulted

not evaluated

Fig. 12: Treatment outcome in new ss+ casesSEA Region, 2004 cohort

0.76051103370.05133565620.04018583040.02810685250.05946573750.0603948897

0.71111111110.11111111110.02222222220.088888888900.0666666667

0.63166345540.1220295440.0463498180.12331406550.03992721040.0367159067

0.49893760870.23181480840.0685166170.04472210080.14827221620.0077366489

0.62068186950.19575524950.04425378190.0322871980.06638067280.0406412283

0.800.2000

0.59304221780.14151114330.08751585430.05888747960.07646312740.0425801776

0.79914529910.01673789170.06445868950.04522792020.07086894590.0035612536

0.6448362720.0403022670.07052896730.02267002520.19899244330.0226700252

0.61027503890.05604566680.1312921640.06694343540.07317073170.0622729632

0.83333333330.04761904760.071428571400.04761904760

0.51917799110.21632490190.06752976120.04791948390.1371566650.0118911969

cured

completed

died

failure

defaulted

not evaluated

Fig. 13: Treatment outcome in retreatment ss+ casesSEA Region, 2004 cohort

0.7720.50.85

0.7210.85

0.72

0.73

0.83

0.8

0.85

0.8631347221

0.8631347221

1997

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate

Treatment success rate

Fig. 14: Trends in case-detection and treatment success ratesSEA Region, 1997-2005

0.190

0.240.7

0.25

0.24

0.26

0.32

0.33

0.39

0.59

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate

Progress in population coverage andDOTS case detection

0.720.50.85

0.7810.85

0.8

0.81

0.82

0.84

0.84

0.85

0.9

1997

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate


Progress in DOTS case detection andtreatment success

0

0.240.7

0.27

0.26

0.31

0.32

0.33

0.317573595

0.9535603715

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate


0.50.85

0.2410.85

0.9

0.85

0.9

0.94

0.86

0.8984375

0.8346666667

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate


Progress in DOTS case detection andtreatment results

0

0.7

0.02

0.26

0.53

0.79

0.91

1.02

0.9938013068

1997

1997

1997

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate


0.50.85

10.85

0.02

0.95

0.91

0.91

0.88

0.884

0.8880350668

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate



0.010

0.0150.7

0.064

0.12

0.24

0.31

0.47

0.58

0.622232589

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate


0.790.50.85

0.81810.85

0.84

0.82

0.84

0.85

0.87

0.862

0.8614231888

1997

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate



0.0740

0.120.7

0.19

0.19

0.2

0.27

0.33

0.54

0.6546850174

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate


0.8130.40.85

0.54510.85

0.58

0.5

0.87

0.86

0.86

0.867

0.895310162

1997

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate



0

0.240.7

0.27

0.26

0.31

0.32

0.33

0.317573595

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

population coverage

DOTS detection rate

0.50.85

0.2410.85

0.9

0.85

0.9

0.94

0.86

0.8984375

1997

1998

1999

2000

2001

2002

2003

2004

DOTS detection rate


0.90

0.820.7

1.06

0.81

0.79

0.87

1.06

1.05

0.9295774648

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate


0.9340.40.85

0.94710.85

0.94

0.94

0.97

0.97

0.95

0.91

0.9545454545

1997

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate



0.250

0.280.7

0.33

0.48

0.56

0.65

0.73

0.84

0.9603416557

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate

Progress in population coverage andDOTS case detection rate

0.7910.50.85

0.81810.85

0.83

0.81

0.82

0.81

0.81

0.806

0.8358051861

1997

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate



0.110

0.160.7

0.44

0.56

0.56

0.57

0.6

0.6955

0.6684196086

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate

Progress in population coverage andDOTS case detection rate

0.8470.50.85

0.86810.85

0.89

0.87

0.86

0.88

0.86

0.87

0.874709183

1997

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate



0.710

0.750.7

0.76

0.68

0.73

0.71

0.7

0.76

0.8649276398

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate


0.7990.50.85

0.76510.85

0.76

0.84

0.77

0.8

0.81

0.808

0.8523421589

1997

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate



0.0050

0.210.7

0.4

0.46

0.73

0.65

0.72

0.72

0.6568361947

1997

1997

1997

1997

1998

1999

2000

2001

2002

2003

2004

2005

population coverage

DOTS detection rate


0.7780.50.85

0.62210.85

0.67

0.77

0.69

0.75

0.74

0.727

0.6835086732

1997

1998

1999

2000

2001

2002

2003

2004

2005

DOTS detection rate



0

0.7

0.59

0.53

0.43

0.467268623

1997

1997

1997

2001

2002

2003

2004

2005

population coverage

DOTS detection rate


0.50.85

10.85

0.73

0.81

0.806

0.798

2002

2003

2004

2005

DOTS detection rate



524751

81706776

104436785

114235538

110383960

84762281

75531230

male

female

Age group (years)

Notification per age groupnew smear-positive cases, 2005

19

4745

5838

2613

2311

149

122

male

female

Age group (years)


4617

5023

4926

5529

5928

5528

5429

5733

6037

7145

8760

&A

Page &P

All TB cases

New smear-positive cases

cases per 100 000 pop.

TB notification rates, 1995-2005

7220

6917

6415

6614

5916

5517

4917

5017

4516

4416

15046

All TB cases




84848

23076

11318

3876

0

1092

0

Bangladesh

2005 Case notification by type of patientTotal notified: 124 210

308

272

387

40

7

4

0

`

Bhutan

2005 Case notification by type of patientTotal notified: 1018

0.8847417616

0.0117555109

0.0382811752

0.007002265

0.0278336045

0.0303856828

Bangladesh

Treatment resultsNew ss+, 2004 cohort (n = 62 694)

167166

14091127

24221758

26881890

20401381

1185764

48533

male

female

Age group (years)


31476257

6243444955

7444445458

7670228443

6465716938

4294610466

246355370

male

female

Age group (years)


846946

1521513916

2090616393

1840113022

1784710927

135097539

63902783

male

female

Age group (years)


01

910

87

51

62

62

54

male

female

Age group (years)


132147

34012376

58773047

58882563

45852101

25571218

1764885

male

female

Age group (years)


148195

19461208

16851111

1722797

1806658

1759532

820230

male

female

Age group (years)


919

341295

520261

724189

918200

657154

424130

male

female

Age group (years)


3950

1345778

37901467

41451215

36661247

25851145

31641801

male

female

Age group (years)


88

136127

14990

11676

11960

5218

4729

male

female

Age group (years)


5118

52

5623

15374

13164

17882

18477

19782

19079

All TB cases




13128

13631

11728

11228

12235

11034

10537

10138

10141

10746

10546

All TB cases




1816

126

1110

2016

3324

4025

4325

7135

8142

9960

11471

All TB cases


cases / 100 000 pop.


9246

8241

6536

6432

5431

4522

4620

4019

4321

4721

3720

All TB cases


Cases per 100 000 pop.


4120

5022

3821

3222

4224

6536

8944

11749

15355

19563

21272

All TB cases




9541

10748

11052

10750

11958

12658

12357

12356

12357

12758

12354

All TB cases




7935

6829

5122

2713

4925

5629

8146

8041

8745

8845

8041

All TB cases




374148

355132

409129

398109

All TB cases




17796

18123

5381

1364

1524

1018

5210

DPR Korea

2005 case notification by type of patientTotal notified: 50 416

506852

392390

170948

75028

17764

72089

58642

India

2005 case notification by type of patientTotal notified: 1 293 713

158640

85373

6142

4446

0

0

0

Indonesia

2005 Case notification by type of patientTotal notified: 254 601

66

23

29

4

0

0

1

Maldives

2005 Case notification by type of patientTotal notified: 123

36541

35601

30252

4615

0

982

0

Myanmar


14617

9474

7013

2344

316

313

0

Nepal


4841

2191

1913

263

55

186

0

Sri Lanka

2005 case notification by type of patientTotal notified: 9449

26437

16520

6703

1606

0

0

0

Thailand


1035

2142

554

36

4

12

0

Timor-Leste

2005 case notification by type of patientTotal notified: 3783

0.784

0.0506666667

0.0453333333

0.0026666667

0.0186666667

0.0986666667

Bhutan

Treatment resultsNew ss+, 2004 cohort (n = 375)

died, 5%

failure,

Five countries account for the majority of HIV burden in the RegionHIV Prevalence in the South-East Asia Region: 2007India 2,500,000Myanmar242,000

Thailand562,000Nepal 70,000Indonesia 193,000

HIV prevalence stable/decreasing in most countriesbut increasing in others.WHO 2007

Indonesia has the fastest growing HIV epidemic in Asia

Determinants for the frequency of HIV-associated TB in a community: SEAR600 million TB infectedTotal population of 1.6 billion4 million HIV infected TB/HIV co-infected3 million new cases per year TB epidemic being primarily driven by the 596 million TB infected non-HIV infected pool

Source: Tuberculosis in the South-East Asia Region, WHO/SEARO, March 2008

Source: Ministry of Health Union of Myanmar, December 2007

WHOLE STATUS

1609

805

HIV status of TB patientsFrom beginning of the Programme

Chart2

1113118

2066939

33012176

415157100

556199114

676242146

812289193

945333219

1063385264

1214434297

1322475323

1337490336

Cumulative Tested TB Patients

Cumualtive HIV +

Cumulative Referred to Enrol

Cumulative HIV Tested TB Patients,HIV + and Referred to Enrol IHC for 2006

Sheet1

MONTH | Freq Percent Cum.

------+-----------------------ENR | Freq Percent Cum.

1 | 123 8.6% 8.6%------+-----------------------HIVRES1

2 | 100 7.0% 15.7%1 | 28 7.3% 7.3%MONTH | 1 2 | Total

3 | 132 9.3% 24.9%2 | 27 7.0% 14.3%601 | 80 31 | 111-----------+---------------+------

4 | 91 6.4% 31.3%3 | 45 11.7% 26.0%602 | 57 38 | 95601 | 80 31 | 111

5 | 155 10.9% 42.2%4 | 27 7.0% 33.1%603 | 72 52 | 124602 | 57 38 | 95

6 | 133 9.3% 51.6%5 | 14 3.6% 36.7%604 | 49 36 | 85603 | 72 52 | 1241 | 18 5.4% 5.4%

7 | 150 10.5% 62.1%6 | 43 11.2% 47.9%605 | 99 42 | 141604 | 51 36 | 872 | 21 6.3% 11.6%

8 | 137 9.6% 71.7%7 | 55 14.3% 62.2%606 | 77 43 | 120605 | 104 42 | 1463 | 37 11.0% 22.6%

9 | 123 8.6% 80.4%8 | 30 7.8% 70.1%607 | 89 47 | 136606 | 77 43 | 1204 | 24 7.1% 29.8%

10 | 165 11.6% 92.0%9 | 47 12.2% 82.3%608 | 89 44 | 133607 | 89 48 | 1375 | 14 4.2% 33.9%

11 | 114 8.0% 100.0%10 | 38 9.9% 92.2%609 | 66 52 | 118608 | 89 45 | 1346 | 32 9.5% 43.5%

------+-----------------------11 | 30 7.8% 100.0%610 | 102 49 | 151609 | 67 53 | 1207 | 46 13.7% 57.1%

Total | 1423 100.0%------+-----------------------611 | 67 41 | 108610 | 104 49 | 1538 | 26 7.7% 64.9%

Total | 384 100.0%612 | 0 15 | 15611 | 68 41 | 1099 | 45 13.4% 78.3%

-----------+---------------+------10 | 33 9.8% 88.1%

Total | 858 478 | 133611 | 26 7.7% 95.8%

Jan1818Cumulative Tested TB PatientsCumualtive HIV +Cumulative Referred to Enrol12 | 13 3.9% 99.7%

Feb2139January111311855 | 1 0.3% 100.0%

Mar3776February2066939601 | 6 25 | 31-------+-----------------------

Apr24100March33012176602 | 12 26 | 38Total | 336

May14114April415157100603 | 13 39 | 52

June32146May556199114604 | 12 24 | 36

Jul47193June676242146605 | 17 25 | 42

Aug26219July812289193606 | 11 32 | 43

Sep45264August945333219607 | 15 33 | 48

Oct33297September1063385264608 | 9 36 | 45

Nov26323October1214434297609 | 16 37 | 53

Dec13336November1322475323610 | 18 31 | 49

1 | 18 5.4% 5.4%December1337490336611 | 23 18 | 41

2 | 21 6.3% 11.6%-----------+---------------+------

3 | 37 11.0% 22.6%Total | 152 326 | 478

4 | 24 7.1% 29.8%

5 | 14 4.2% 33.9%

6 | 32 9.5% 43.5%

7 | 46 13.7% 57.1%

8 | 26 7.7% 64.9%

9 | 45 13.4% 78.3%

10 | 33 9.8% 88.1%

11 | 26 7.7% 95.8%

12 | 13 3.9% 99.7%

55 | 1 0.3% 100.0%

-------+-----------------------

Total | 336

Chart5

858

478

HIV status of TB patientsFrom January (06) to November (06)

Chart6

Chart6

329

149

Referred to enrol IHC(TB/HIV co-infected patients,2006)

Chart3

35

3115

32468

20360

5720

116

20

Male

Female

Age group & sex distribution of TB/HIV coinfected patients

Chart10

195

378

146

27

1

12

46

Type of TB in TB/HIV coinfected patients

Sheet5

DiedNot have form 10RefuseDefaultOld ageBedriddenIn jailIVDUAway from homeTOARV from World VisionReasonNumber

CATZ5101Form 10 problem43

MHAM4231111Died20

AMTZ85411141Refuse with any reasons9

CMTZ35421Transferred to other townships5

Travellingin hospitalOn going processDefaulted during TB treatment3

112Bedridden2

Not in township TB register2

On going process2

Away from home1

In hospital1

In jail1

IVDU1

Old age1

Received ARV from World Vision1

Travel with anti-TB drugs1

Total93

1241

671

1912

1912

1336

0.6987447699

36

Sheet2

1 | 858 478 | 1336HIV ( - )HIV ( + )Referred to enrol IHCRemaining to enrol IHC

2 | 12 40 | 52858478329149

4 | 25 7 | 32

HIV ( - )HIV ( + )

1609805Referred to enrol IHC329

Remaining to enrol IHC149

152 326 | 478

AMTZ | 30 103 | 133

CATZ | 22 57 | 79

CMTZ | 36 58 | 94

MHAM | 31 61 | 92F | 5 15 68 60 20 6 0 | 174

PGTG | 33 47 | 80M | 3 31 324 204 57 11 2 | 632

-----------+---------------+------

Total | 152 326 | 478

0-1415-2425-3435-4445-5455-6465 and above

Male33132420357112

Female51568602060

AMTZ | 199 133 | 332

CATZ | 141 79 | 220

CMTZ | 221 94 | 315

MHAM | 181 92 | 273

PGTG | 116 80 | 1961 | 195NSS+195

-----------+---------------+------2 | 378NSS nge378

Total | 858 478 | 13363 | 146EP146

4 | 27Relapse27

5 | 1TAF1

6 | 12TAD12

Remaining to enrol IHC2557 | 46Others46

Referred to enrol IHC550

Sheet2

0

0

HIV status of TB patients From January (06) to November (06)

Chart9

0

0

HIV status of TB patientsFrom beginning of the programme

Chart1

0

0

Referred to enrol IHCTB/HIV co-infected patients from the beginning of program

Chart4

10528199

5836221

6230181

5722141

4733116

Enrollment of IHC program among TB/HIV co-infected patients by township

Referred IHC

Remaining

HIV ( - )

Chart7

6311019

174590

HIV +

HIV -

HIV status of TB patients by sex (From the beginning of programme)

Chart8

608

583

462

444

320

Number of HIV tested TB patients by township

Sheet4

1609807

2064

3922

HIV -

HIV +

HIV status of TB patients & their relatives

Chart11

652

153

Disease classification of TB/HIV coinfected patients

Sheet6

Registered adult TB patients1912

Tested for HIV1336Relatives tested84

TB/HIV co-infected patients478HIV infected47

HIV infected patients referred to IHC326

TBOUTCOME

HIVRES1 | 0 1 2 3 4 5 6 | Total

-----------+--------------------------------------------------+------

1 | 44 318 339 3 19 3 15 | 741

2 | 9 78 196 3 43 1 1 | 331

3 | 0 0 1 0 0 0 0 | 1CuredCompletedDefaultedDiedFailedT/outNot recordedTotal

-----------+--------------------------------------------------+------HIV ( - )31833931931544741

Total | 53 396 536 6 62 4 16 | 1073HIV ( + )78196343119331

Total396535662416531072

An expected value is < 5. Chi square not valid.

Chi square = 86.01

Degrees of freedom = 12Spouse52

p value = 0.00000000 6431

Referred IHCRemainingHIV ( - )HIV ( + )

Aungmyaethasan10528199227133

Chanmyathazi583622125794HIVRES1

Mahaaungmyae623018121192SEX | 1 2 3 | Total

Chanayethasan572214116379-----------+----------------------+------

Pyigyitagon473311614980F | 590 174 0 | 764

1007M | 1019 633 1 | 1653

-----------+----------------------+------

Total | 1609 807 1 | 2417

AMTZ | 30 103 | 133

CATZ | 22 57 | 79Aungmyaethasan608

CMTZ | 36 58 | 94Chanmyathazi583

MHAM | 31 61 | 92Chanayethasan462HIV +HIV -

PGTG | 33 47 | 80Mahaaungmyae444Male6311019

-----------+---------------+------Pyigyitagon320Female174590

Total | 152 326 | 478

AMTZ | 608 25.2% 25.2%

CATZ | 462 19.1% 44.3%199221181

CMTZ | 583 24.1% 68.4%303631

MHAM | 444 18.4% 86.8%1035861

PGTG | 320332315273

HIV -HIV +

A1 | 1609 807 1 | 2417TB patients1609807

2 | 20 64 0 | 84Spouse2064

4 | 39 22 0 |Child3922

PTB652

EPTB153

Characteristics of TB/HIV Patients in Thailand*

Median age 3480-90% with CD4 < 200High death rates, up to 43%-56% in some settings; Most deaths occur in first 2-3 monthsART during TB treatment reduces mortality dramatically: 4 -7% when provided ART (Akksilp, et. al., Emerg Infect Dis, 2007) 70% male; but HIV now altering the predominantly male pattern of TB disease in areas of high HIV prevalence

*multiple data sources

TB notifications: Average age and sex by province: Indonesia (2003)Source: Directorate-General of DC and EH, Ministry of Health , Indonesia

TB-HIV prevalence in SEAR

Source: *Ministries of Health, SEAR Member countries, 2007; Global TB Report WHO, 2008

Incidence of TB based on Nationwide ARTI survey: IndiaNorthWestEastSouthSource: RNTCP, India, MoH &FW, India; 2006

India: states with high HIV prevalence TAMILNADUANDHRAPRADESHMAHARSHTRAMANIPURNAGALANDGUJARATMADHYA PRADESHORISSAWESTBENGALBIHARJHARKHANDCHATTISGARHUTTAR PRADESHUTTARANCHALJAMMU &KASHMIRKERALARAJASTHANHARYANAPUNJABGOAHIMACHAL PRADESHDELHIDAMAN & DIUD&N HAVELISIKKIMMEGHALAYATRIPURAMIZORAMARUNACHALPRADESHASSAMLAKSHADWEEPMaharashtraAndhra PradeshKarnatakaTamil NaduQ: What is the likely impact of HIV on the future of TB control in India?Source: National AIDS Control Organization, MoH &FW, India; 2007

TB Infection HIV/TB Co-InfectionActive TB and HIVHIV InfectionTB ScreeningIPT DOTS CPTARTHIV/AIDS Care & SupportVCTCondomsSTDBlood SafetyHarm ReductionMTCTStrategy IIIReduce morbidity and mortality of HIV associated active TB and AIDSStrategy IIPrevent progression of latent TBStrategy IPrevent HIV Regional Strategic framework of interventions for TB/HIV interventionsStrategy IV: Strengthening the health systems response to TB/HIV

Building capacity for implementing TB/HIV collaborative activitiesModule 1: Introduction to TB/HIV Policies and ProgrammesModule 2: TB/HIV SurveillanceModule 3: TB/HIV InterventionsModule 4: TB/HIV Planning and ManagementModule 5: Translating knowledge and lessons learned into actionJoint programme managers meeting 2004, 2006, and 2008 Inter-country Training of trainers: 2005 and 2006In-country technical assistance missions

Progress at Country LevelFully integrated nation-wide implementation Thailand

Rapidly scaling up: India, Myanmar

Pilot projects: Indonesia and Nepal

Preparing for interventions:Bangladesh*, Bhutan, Sri Lanka, and Timor-Leste*HIV NGOs in Bangladesh are spearheading TB/HIV interventions; use of IPT, modifying the R & R formats, cross-referrals, provision of ART and CPT

Establish mechanisms of coordination

Decrease the burden of TB in PLHA

Decrease the burden of HIV in TB patients

Increasing Acceptance of HIV testing among TB Patients

Percent of patientsSource: ODPC 7, Ubon Ratchatani Province, Thailand

TB patients tested and referred to IHCs Myanmar Source: Ministry of Health, Union of Myanmar, November 2007

total

2337

1372

Chart1

1077201326

2428558819

2666558891

2839558940

30705671018

31995841057

33826071120

35676201181

37486591241

39406951308

40787511355

42288291401

43468561465

Tested

Referred to enrol

HIV+

Year/Month

Number

Sheet1

MONTH | Freq Percent Cum.

------+-----------------------ENR | Freq Percent Cum.

1 | 123 8.6% 8.6%------+-----------------------

2 | 100 7.0% 15.7%1 | 28 7.3% 7.3%601 | 86 37 | 1233131

3 | 132 9.3% 24.9%2 | 27 7.0% 14.3%602 | 60 40 | 1003869

4 | 91 6.4% 31.3%3 | 45 11.7% 26.0%603 | 75 57 | 13252121

5 | 155 10.9% 42.2%4 | 27 7.0% 33.1%604 | 53 38 | 9136157

6 | 133 9.3% 51.6%5 | 14 3.6% 36.7%605 | 107 48 | 15542199

7 | 150 10.5% 62.1%6 | 43 11.2% 47.9%606 | 81 52 | 13343242

8 | 137 9.6% 71.7%7 | 55 14.3% 62.2%607 | 97 53 | 15048290

9 | 123 8.6% 80.4%8 | 30 7.8% 70.1%608 | 89 48 | 13745335

10 | 165 11.6% 92.0%9 | 47 12.2% 82.3%609 | 68 55 | 12353388

11 | 114 8.0% 100.0%10 | 38 9.9% 92.2%610 | 111 54 | 16549437

------+-----------------------11 | 30 7.8% 100.0%611 | 70 44 | 11441478

Total | 1423 100.0%------+----------------------------------+---------------+------478

Total | 384 100.0%Total | 897 526 | 1423

Jan2525TestedReferred to enrolHIV+

Feb265120051077201326MONTH | 1 2 | Total

Mar3990357200624285588191351493-----------+---------------+------HIVRES1

Apr24114007,Jan266655889123872601 | 80 31 | 111MONTH | 1 2 | Total

May25139007,Feb283955894017349> 72.1% 27.9% > 8.4%-----------+---------------+------

June32171907,Mar3070567101823178| 9.5% 6.6% |601 | 80 31 | 111

Jul332041707,Apr3199584105712939602 | 57 38 | 95> 72.1% 27.9% > 8.3%

Aug362402307,May3382607112018363> 60.0% 40.0% > 7.2%| 9.3% 6.5% |

Sep372771307,June3567620118118561| 6.8% 8.1% |602 | 57 38 | 95

Oct313083907,July3748659124118160603 | 72 52 | 124> 60.0% 40.0% > 7.1%

Nov183263607,Aug3940695130819267> 58.1% 41.9% > 9.4%| 6.6% 7.9% |

3265607,Sep4078751135513847| 8.5% 11.0% |603 | 72 52 | 124

7807,Oct4228829140115046604 | 48 36 | 84> 58.1% 41.9% > 9.3%

2707, Nov4346856146511864> 57.1% 42.9% > 6.4%| 8.4% 10.9% |

0| 5.7% 7.6% |604 | 51 36 | 87

601 | 80 31 | 1110605 | 99 42 | 141> 58.6% 41.4% > 6.5%

9

17

602 | 57 38 | 9523> 70.2% 29.8% > 10.7%| 5.9% 7.5% |

603 | 72 52 | 12410611061322322| 11.7% 8.9% |605 | 104 42 | 146

604 | 51 36 | 87111117231353606 | 77 43 | 120> 71.2% 28.8% > 10.9%

605 | 104 42 | 14695126738391> 64.2% 35.8% > 9.1%| 12.1% 8.8% |31

606 | 77 43 | 120124139152443| 9.1% 9.1% |606 | 77 43 | 12038

607 | 89 48 | 13786147736479607 | 89 47 | 136> 64.2% 35.8% > 9.0%52

608 | 89 45 | 134142161942521> 65.4% 34.6% > 10.3%| 9.0% 9.0% |36

609 | 67 53 | 120120173943564| 10.5% 10.0% |607 | 89 48 | 13742

610 | 104 49 | 153136187547611608 | 87 43 | 130> 65.0% 35.0% > 10.3%43

611 | 68 41 | 109133200844655> 66.9% 33.1% > 9.9%| 10.4% 10.0% |48

-----------+---------------+------118212652707| 10.3% 9.1% |608 | 89 45 | 13445

Total | 858 478 | 1336151227749756609 | 66 52 | 118> 66.4% 33.6% > 10.0%53

108238541797> 55.9% 44.1% > 9.0%| 10.4% 9.4% |49

15240015812| 7.8% 11.0% |609 | 67 53 | 12041

236263672884610 | 102 48 | 150> 55.8% 44.2% > 9.0%478

172280849933> 68.0% 32.0% > 11.4%| 7.8% 11.1% |

| 12.1% 10.2% |610 | 104 49 | 153

611 | 67 40 | 107> 68.0% 32.0% > 11.5%

> 62.6% 37.4% > 8.1%| 12.1% 10.3% |

| 7.9% 8.5% |611 | 68 41 | 109

-----------+---------------+------> 62.4% 37.6% > 8.2%

Total | 844 472 | 1316| 7.9% 8.6% |

| 64.1% 35.9% |-----------+---------------+------

Total | 858 478 | 1336

| 64.2% 35.8% |

Chart4

845571157104

835594213163

728435143104

66544513893

51131513177

Registered adult TB

VCCT accepted & tested

Co-infected

Referred to enrol

Township

Number

VCCT status of (Jan 2005 to Nov 2006) registered adult TB patients

Sheet2

MHAMCATZAMTZPGTGCMTZTownshipRegistered adult TBVCCT accepted & testedCo-infectedReferred to enrol

Registered adult TB7286658355118453584CMTZ845571157104

VCCT accepted & tested4234415773135602314AMTZ835594213163

Co-infected143138211129153774MHAM728435143104

Referred to enrol1049316376102538CATZ66544513893

PGTG51131513177

MHAMCATZAMTZPGTGCMTZ

Registered adult TB728665835511845

VCCT accepted & tested435445594315571

Co-infected143138213131157

Referred to enrol1049316377104

Chart2

47029586

434305124

40324986

33920773

26618574

Registered adult TB

VCCT Accepted & Tested

HIV +

VCCT Accepted & HIV Tested Adult TB Patients(2006 January to November)

Chart3

671

1241

Proportion of VCCT accepted & HIV tested TB patients for 2006

Sheet4

MHAMCATZAMTZPGTGCMTZVCCT Accepted & Tested23372005/62580243

Registered adult TB7286658355119703709No Tested1372

VCCT Accepted & Tested4274465843165642337

1372

Sheet6

MHAM(05)CATS(05)AMTS(05)PGTG(05)CMTZ(05)Registered adult TBVCCT accepted & testedRegistered adult TBVCCT accepted & tested

0-141048799128136AMTZ401272CMTZ470295

15-64325326401245375CMTZ375265AMTZ434305

65 and above2222351429CATZ326234MHAM403249

MHAM325174CATZ339207

MHAM(06)CATS(06)AMTS(06)PGTG(06)CMTZ(06)PGTG245128PGTG266185

0-141071151369012219121241671

15-64403339434266470

65 and above2417371418

MHAMCATZAMTZPGTGCMTZregtested

2005325326401245375167216721073

2005 TESTED174234272128265107319121241

2006403339434266470191235842314

2006 TESTED249207305185295124119

2333

2004 TESTED247331965.0948660714

35842416

67.4107142857807

1609




Co-infected143138213131157782





Co-infected1087711080114489


Amtzcmtzmhamcatzpgtg

jan4935553033

feb4845383428

mar5564643635

apr4347383036

may5158673137

june5060434940

july3853274432

aug5053464128

sep3947323419

oct4336353429

4664984453633172089

Sheet5

MHAM(05)CATS(05)AMTS(05)PGTG(05)CMTZ(05)

0-141048799128136

15-64325326401245375

65 and above2222351429

MHAM(06)CATS(06)AMTS(06)PGTG(06)CMTZ(06)MHAM(06)CATS(06)AMTS(06)PGTG(06)CMTZ(06)

0-14107115136901222005347348436259404

15-644033394342664702006>14 year460401506308525

65 and above24173714182007 aug378295384269415

11851044132683613445735


2005325326401245375

2005 TESTED174234272128265AMTZ35869457272

200640333943426647094769045305

2006 TESTED249207305185295CATZ39717450234

60585534207

2004 TESTED24733CMTZ40878058265

66828166295

MHAM7417848174

71716542249

PGTG13363841128

pt2415notr3646545827185

tyear2333treat2379

82

36

46235742361

29

R12417NO PT27

NO TB2

2334

27

23612361

Sheet3

MHAM(05)MHAM(06)CATS(05)CATS(06)AMTS(05)AMTS(06)PGTG(05)PGTG(06)CMTZ(05)CMTZ(06)Registered adult TBVCCT Accepted & TestedHIV +

0-14104107871159913612890136122CMTZ47029586

15-64325403326339401434245266375470AMTZ434305124

65 and above22242217353714142918MHAM40324986

CATZ33920773

1912PGTG26618574

19121241443798

Current selection: (NOTREAT=2) AND (TYEAR>60)NO testedVCCT Accepted & Tested

1116711241

TYEAR442

TOWNSHIP | 61 62 63 64 | Total

-----------+-----------------------------+------MHAMCATZAMTZPGTGCMTZ1336

AMTZ | 94 75 90 45 | 30453253264012455001239

CATZ | 60 58 55 33 | 206640333943426647097

CMTZ | 66 82 81 66 | 2957286658355119701239

MHAM | 71 71 65 42 | 249673

PGTG | 46 54 58 27 | 1851912

-----------+-----------------------------+------

Total | 337 340 349 213 | 1239



Chi square = 14.09VCCT Accepted & Tested42744658431656423371912

Degrees of freedom = 121241

p value = 0.29472916671

403

Current selection: ((NOTREAT=2) AND (TYEAR>60)) AND (TOWNSHIP="AMTZ")339

434

MONTH470

TYEAR | 601 602 603 604 605 606 607 6081646

-----------+--------------------------------------------------------1912

61 | 24 34 25 6 4 1 0 0266

62 | 0 0 0 17 26 19 6 2

63 | 0 0 0 0 0 0 21 31

64 | 0 0 0 0 0 0 0 0

-----------+--------------------------------------------------------

Total | 24 34 25 23 30 20 27 33

MONTH

TYEAR | 609 610 611 | Total

-----------+----------------------+------

61 | 0 0 0 | 94

62 | 4 0 1 | 75

63 | 30 8 0 | 90

64 | 0 19 26 | 45

-----------+----------------------+------

Total | 34 27 27 | 304

An expected value is < 5. Chi square not valid.

Chi square = 705.17

Degrees of freedom = 30

p value = 0.00000000

Intensified TB/HIV package for high HIV burden statesIntensified TB/HIV packageRoutine offer of VCT to all TB patientsOne page guidance tool developedProvision of CPT to HIV infected TB ptsProgrammatic implementation of shared confidentiality of HIV status in HIV high burden statesCPT at DOTS centres by RNTCPHIV status, CPT, and ART integrated into TB programme records and reportsMizoramPondicherryGoa9 states; 158 districts;317 million population

Intensified TB/HIV package- Expanded RNTCP recording & reportingCase-finding and treatment outcome reportsTB Treatment cards with HIV status, CPT, ARTTB registers with HIV status, CPT, ART

Expansion of HIV counseling and testing services in IndiaThe RNTCP of India has 12,000 microscopy centres and over 200,000 centres offering TB treatment

Challenges in Linking HIV-infected TB Patients for Care and Support* Excludes 94 patients already on ART at TB diagnosis

Slow expansion of HIV services is the rate limiting step.

--SEAR NTP Managers , November 2006

Issues (2) Are the programs equipped?ProgrammaticLevel at which TB and HIV services are delivered (HIV: centralized, TB: decentralized to sub-district level)Availability of diagnostics and drugs: HIV test kits, TB cultures, X-rays limitedAvailability of trained, skilled and motivated personnel (both programs)Existence of plans, with clear indicators and targets (TB, HIV and general health services)Operational systems for cross-referral, linkageslevel of involvement and approaches of NGOs and private providers in the two programmesOtheradministrative, ethical, social, etc.

Issues: (3) A firm footing??

Relative to the problem---

Attention at higher policy level, to TB/HIV as an issue; TB programs still the primary drivers ?

Mandated well-functioning TB-HIV coordinating/technical working groups with representation from all concerned sectors at the planning and operational level?

TB a priority for national HIV/AIDS programmes?

Health system constraints?!

Mindsets!!.. also,

stigmatization/fear on part of health workers

Issues (4): Implementation

Surveillance, monitoring and evaluationTB-HIV SurveillanceNeed to move towards routine referral and reporting. In the meantime, what surveillance strategies, in light of heterogeneous HIV prevalence in most countries? Monitoring, EvaluationMost countries yet to firmly adopt indicators and to set targets that are relevant to their programmesJoint M and E just beginningDecreasing the burden of TB in PLHAIntensified case findingNeed to establish TB screening into longitudinal care among PLWHAMost health providers still not thinking TB among PLWHA and other high risk groupsIsoniazid preventive therapy Most question feasibility; others worry about amplifying INH resistance Infection controlLargely not in place; lack policies, clear operational guidelines for what to do in programme context

Issues(5)Implementation

Decreasing the burden of HIV in TB patientsRoutine cross-referralLimited VCT centres; Limited availability of HIV test kitsIncreased burden on available (yet very limited) VCT centresSelective referral in low HIV settings(missed opportunities)

HIV screening of TB suspectssheer numbers of non-HIV infected; yield seen as low vs increased load on system; inviting unnecessary stigmatizationHIV preventionLimited to limited VCT, HIV treatment facilities, and TB-HIV pilot/program sitesCotrimoxazole (CPT) and Antiretroviral therapy (ART)Policy for CPT exists; practice highly variable Policy for ART in line with international guidelines; CD4 and ART available only at secondary and tertiary care facilitiesWidespread (mis) use of both first and second line ART and ATT in private sector Use of Rifabutin ? Secondline ART? Second-line ATT?

The Way Forward: ImplementationEnsure adequate capacity (human, financial resources, infrastructure)Focus on implementation!!Urgently address programmatic challenges in ensuring diagnosis and treatment Expand best practice interventions for ICF, IC and IPT with HIV programmes as they scale upEngage more with private providers and communitiesAddress sociological challenges: stigma, high-risk behaviours; psycho-social support systemsImprove surveillance, monitor and evaluate interventions and their impact

The way forward: establish a firm foundation

Advocate at the highest levels for commitment to addressing TB/HIV based on evidence (need better surveillance)

Prioritize TB on the agenda of national HIV/AIDS programmes as they scale up not just another opportunistic infection

Establish a well-functioning Regional level and national TB-HIV technical committees, with representation from all stakeholders and partners

Help address health system constraints

TB/HIV targets: SEA Regional Strategic Plan for TB Control, 2006-2015

IndicatorCurrentlyBy 2010National coordinating bodies/technical working groups established5/11 countriesAll countries

Proportion of newly diagnosed TB patients tested for HIV70%Proportion of VCT attendees screened for TBLargely unknown>70%Proportion of PLWHA with active TB receiving ATTUnknown>85%Proportion of TB patients with HIV eligible for ART, who receive ART80%

Of 1389 HIV-infected TB patients registered in 2005 in the Active Surveillance Network, the median age was 34 (range: 1, 82) and almost 70% were male. Of 931 (67%) with CD4 counts recorded, 83% had CD4 < 200 cells/mm3; only 9% had CD4 > 300 cells/mm3. In 999 HIV-infected TB patients registered in 2005 from Region 10, 515 (52%) had CD4 recorded; of these, 93% had CD4 < 200 cells/mm3 and only 5% had CD4 > 300 cells/mm3. In the DCT project conducted in 12 hospitals throughout Thailand in 2006, 91% of 45 HIV-infected TB patients had CD4 < 200 cells/mm3. A large proportion of HIV-infected TB patients were diagnosed with HIV before their TB diagnosis, 814 (59%) of 1389 patients in the Active Surveillance Network and 87 (47%) of 185 in the DCT project. Nationally, treatment outcomes stratified by HIV status were not available from 2001-2005. In the Active Surveillance Network, the treatment success rate was 57% in 1335 HIV-infected TB patients compared with 76% in 3012 HIV-uninfected TB patients and 61% in 1261 HIV-unknown TB patients (p

tb-hiv in the south-east asia region 13 th core group meeting of the tb/hiv working group april...

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