TB/HIV UpdateCentral TB Division

Estimated HIV prevalence in new TB cases, 2008

National estimate – 4.85% of Incident TB cases are HIV positive

Proportion of Registered TB patients who are HIV+, 1q10

<1%1%-4.9%5%-9.9%

>10%

Highly Variable!!

RNTCP: HIV status among TB patients registered for DOTS1Q-2Q 2009 Karnataka State

District

Total TB patients registered for DOTS

No. known to be tested for HIV (%)

Of the number tested for HIV, no. known to be HIV infected (%)

Minimum % HIV positive among registered TB patients

BAGALKOT 1114 913 82% 423 46% 38%

BELGAUM 2544 1812 71% 493 27% 19%

BIJAPUR 1135 790 70% 340 43% 30%

DHARWAD 931 612 66% 116 19% 12%

GADAG 530 332 63% 54 16% 10%

HAVERI 750 577 77% 67 12% 9%

UTTARA_KANNADA 646 359 56% 54 15% 8%

BIDAR 856 649 76% 66 10% 8%

BELLARY 1528 1075 70% 133 12% 9%

GULBARGA 1922 959 50% 152 16% 8%

KOPPAL 877 757 86% 134 18% 15%

RAICHUR 1456 1193 82% 187 16% 13%

KARNATAKA 34165 24246 71% 3977 16% 12%Source: Central TB Division, 2009

Treatment outcomes for HIV-positive and HIV-negative TB patients, 2006 cohort

The numbers under the bars are the numbers of patients included in the cohort

Treatment Outcomes of HIV positive and HIV negative TB patients, 4q08

0%

20%

40%

60%

80%

100%

HIV+ HIV- HIV+ HIV-

Transfer Out

Default

Failure

Death

Success

NSP TB Patients All TB Patients

(N=2034) (N=141304) (N=5422) (N=345661)

Lawn et al, CROI 2007

After TB diagnosis, delayed ART initiation associated with higher death rates

Mortality rate** (95% CI)

Early arm

8.28

(6.42 – 10.69)

Late arm

13.77 (11.20 – 16.93)

** per 100 person-years

CAMELIA STUDY

SIGNIFICANT REDUCTION OF MORTALITY IN THE EARLY ARM

ANRS 1295/12160 - CIPRA KH001/10425 ANRS 1295/12160 - CIPRA KH001/10425 studystudy

0.60

0.65

0.70

0.75

0.80

0.85

0.90

0.95

1.00

Pro

bab

ility

of su

rviv

al (

%)

0 50 100 150 200 250Time from TB treatment initiation (weeks)

Early arm Late arm

Mortality rate** (95% CI)

INTEGRATED

5.4

(3.5-7.9)

SEQUENTIAL

12.1 (8.0-17.7)

** per 100 person-years

Karim et al, Durban, SOUTH AFRICA

EARLY ART INITIATION SIGNIFICANTLYREDUCES MORTALITY

“Nationally, RNTCP should be able to reverse the increases in TB burden due to HIV but, to ensure that TB mortality is reduced by 50% or more by 2015, HIV-infected TB patients should be provided with antiretroviral therapy in addition to the recommended treatmentfor TB.”

Summary: TB-HIV Interaction in India• India has the highest burden of TB, and a high

burden of HIV in the world• Most TB is among persons without HIV;

magnitude variable• HIV may slow down TB control efforts in India

– Particularly efforts to reduce mortality

• Enormous need for improved TB-HIV programme collaboration

Response to TB-HIV

The STOP TB Strategy, 2009 Updated language underlined

2006/rev. 2009

1. Pursue high-quality DOTS expansion and enhancementa. Secure political commitment, with adequate and sustained financing b. Ensure early case detection, and diagnosis through quality-assured bacteriologyc. Provide standardised treatment with supervision, and patient supportd. Ensure effective drug supply and management e. Monitor and evaluate performance and impact

2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations

a. “Scale–up” collaborative TB/HIV activitiesb. Scale-up prevention and management of multidrug-resistant TB (MDR-TB)c. Address the needs of TB contacts, and poor and vulnerable populations

3. Contribute to health system strengthening based on primary health care a. Help improve health policies, human resources development, financing, supplies, service

delivery and informationb. Strengthen infection control in health services, other congregate settings and householdsc. Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL) d. Adapt approaches from other fields and sectors, and foster action on the social determinants

of health4. Engage all care providers

a. Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches

b. Promote use of the International Standards for Tuberculosis Care (ISTC)5. Empower people with TB, and communities through partnership

a. Pursue advocacy, communication and social mobilizationb. Foster community participation in TB care, prevention and health promotionc. Promote use of the Patients' Charter for Tuberculosis Care

6. Enable and promote researcha. Conduct programme-based operational research, and introduce new tools into practiceb. Advocate for and participate in research to develop new diagnostics, drugs and vaccines

Evolution of TB-HIV collaborative activities in India

• 2001–First TBHIV “Joint Action Plan” developed; Basic activities in 6 high-HIV burden states

• 2003- Cross referral piloted in MH and initiated in 6 states• 2004–Expanded to 8 additional States• 2005–Joint training modules, surveillance• 2007–Expanded surveillance, CPT/Routine referral pilot, National

Framework for TB/HIV• 2008–National Framework revised, all-India implementation begins

with Intensified package in 9 states

• 2009 – National Framework revised, Intensified package scaled up to include 8 more states

• 2010 – Intensified package launched in 11 states

• Currently 11 states implementing (TN,AP,KA,MH,PD,GA,MZ,MN,NG,GU,DL)• Launched in 7 states (AS,WB,OR,KE,RJ,PN,CH) IN 2009• Rolled out in 11 states in 2010 (HR,UK,HP,JH,CG,TR,ArP,ME,SI,MP,UP)

Intensified TB-HIV package - Nationwide

coverage by 2012

Implementing Launched (2009)Launched (2010)

National TB/HIV Framework 2009…1

All States Intensified Package States

District and State-Level Coordination mechanisms between NACP and RNTCP

Uniform Intensified TB Case Finding at all ICTCs, ART Centres, and Community Care Centres with Line-list

and Standard ReportingTraining in basic TB/HIV

module Additional training on

Intensified TB/HIV Package

National TB/HIV Framework 2009…2All States Intensified Package States

Referral of TB patients for HIV-testing based on HIV risk

factors (selective referral)

Routine referral of all TB patients for voluntary HIV-

counselling and testing (ISTC 14)

Linking HIV-infected TB patients to HIV care and

support, including CPT & ART

Addition: Decentralized CPT(ISTC 15)

Core TB/HIV recording and reporting from NACO MIS and

RNTCP (PMR)

Addition: Expanded TB/HIV recording and reporting(Shared Confidentiality)

All TBHIV Training Modules revised

A new “TBHIV module for ART centre staff” created

• Intensified TB case finding at ART centres with standardised R&R

• Rifabutin use among HIV-infected TB patients receiving Second line ART or Alternative First line ART (containing Protease Inhibitors) approved

• Infection control guidelines for ART centre setting included

• ART in HIV-infected TB patients – regimen, timing of initiation, special situations clarified

International & National Guidelines for ART in HIV-infected TB patients

WHO (2009) NACO (2009)

Who is eligible? ALL, regardless of CD4 (strong recommendation, low

quality of evidence)

ALL Stage 4 (EP-TB, disseminated, miliary)

CD4<350 (Pulm)

When to start? Start TB treatment first, followed by ART as soon as possible after starting

TB treatment.(strong rec, moderate evidence)

Start TB treatment first, followed by ART as soon as possible, 2 weeks after starting TB

treatment

What to start? Use EFV as the NNRTI in patients starting ART

while on TB treatment.

Use EFV as the NNRTI in all TB patients

receiving ART

TB/HIV Performance

66%62%60%

34%44%

54%

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

4q08 1q09 2q09 3q09 4q09 1q10

Num

ber o

f Reg

iste

red

TB P

atien

ts Unknown HIV status

Known HIV status

Trends in Number (%) of registered TB patients with known HIV status, 4q08-1q10

Proportion of TB patients with known HIV status, States, 1q10

87%83% 80% 81% 78%

66% 67%

52%57%

29%37%

26%

13%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Goa KA AP TN PD India GU DL MH MN NG MZ AS

Proportion of TB patients with known HIV Status, 1q10

<49.9%50%-79.9%>80%

Proportion of Registered TB patients who are HIV+, 1q10

<1%1%-4.9%5%-9.9%

>10%

Number (%) of HIV+ TB patients receiving CPT during TB treatment, 4q08-2q09

By quarter of TB registration85%

74%68%

0100020003000400050006000700080009000

4q08 1q09 2q090%10%20%30%40%50%60%70%80%90%

Number of HIV+TB patients receiving CPT % of HIV+TB patients receiving CPT

Number (%) of HIV+ TB patients receiving ART during TB treatment, 4q08-2q09

By quarter of TB registration47%43%

41%

0500

100015002000250030003500400045005000

4q08 1q09 2q090%

10%

20%

30%

40%

50%

Number of HIV+TB patients receiving ART % of HIV+TB patients receiving ART

Trends in Number of TB suspects referred from ICTC to RNTCP 2006–2009

3.5%3.9%

5.2%6.1%

0

50000

100000

150000

200000

250000

300000

350000

2006 2007 2008 20090.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

No. TB suspects referred % of ICTC Clients referred

Trends in TB case detection from ICTC to RNTCP referrals, 2006–2009 (till September)

77% 81% 82% 84%

05000

10000150002000025000300003500040000

2006 2007 2008 20090%10%20%30%40%50%60%70%80%90%

No. TB cases diagnosed from ICTC referrals % of TB cases put on DOTS

Next Steps – 2010-15• Intensified TB/HIV package - Nationwide coverage by 2012

– Provider-initiated HIV testing for all TB patients– Immediate and accountable linkage of HIV-infected TB patients to

NACP for HIV care and treatment• Intensified TB case finding and reporting – Consolidation in

all HIV care settings• Completed clinical and operational research on IPT for

TB/HIV with policy decisions• Implementation of airborne infection control measures• HIV Surveillance among TB suspects at some sentinel sites• RCT among HIV-infected TB patients comparing daily v/s

intermittent regimens

Role of Medical College in TB/HIV collaborative activities

• Academics– Frequent updates / CMEs for faculty and students– Demonstration of TB/HIV care settings to students

• Patient Care– Implementation of ICF and IC at ICTCs and ART centres– Implementation of PITC for TB patients and Early ART

initiation for HIV-infected TB patients• Research

– Operational Research and PG Thesis– Funding available under RNTCP

• Quality Assurance– Part of RNTCP Internal Evaluations and Joint TB/HIV Visits– Peer Pressure on professional colleagues to follow ISTC

Thanks..

A dedicated webpage for TB-HIV