U. S. Senate Briefing World TB Day

Celine Gounder, MD, ScMCenter for TB Research, Johns Hopkins University

Director for Delivery, CREATE

On behalf of the IDSA/HIVMA Center for Global Health Policy

Epidemiology

• 9.4 million new cases of TB in 2008.• 1.3 million people died from TB in 2008.• TB is the #1 cause of death among HIV-

infected persons.• 1/3 of AIDS-related deaths are due to TB.• Over 2,000 people in Africa die from TB per

day.

Estimated incidence of TB (per 100,000 population per year) 2008

Malawi

• Funding from USG:– PEPFAR FY 2008: $23.9 million

• Including support from CDC for laboratory strengthening

– USAID FY 2008: $1.3 million– Global Fund disbursements to date for TB, HIV and HSS

:• $2.8 million for TB• $21.3 million for Health Systems Strengthening• $248 million for HIV• Total $272.1

– U.S. Contributions :1/3 or $81.7 million

Community sputum collection points

Project Hope sites in Mulanje, Malawi

Specimen transport

Sputum smear microscopy

Scaling up of sputum smear microscopy is supported by USAID’s TB CAP.

SWAp: Sector Wide Approaches

Information systems and evaluation

Information systems and evaluation

Baobab Health

Reference: World Health Report 2006.

Limits to task shifting

Doctors trained in sub-Saharan Africa working in OECD countries

Reference: World Health Report 2006.

TB is a women’s health issue.• Reductionist view of women’s health

= reproductive and maternal health• Tuberculosis is a leading killer of women.

– 700,000 women died from TB in 2008.– 536,000 women died from maternal causes in 2005.– Third leading cause of death among women ages 15-44.– Feminization of the HIV epidemic higher burden of TB in women– More among women than men despite low burden of HIV:

• Afghanistan• Pakistan

• To better serve women, TB should be integrated with HIV, antenatal, reproductive health, family planning and STI treatment services.

References: WHO 2009 Women and TB fact sheet.Maternal mortality in 2005. World Health Organization, Geneva, 2007.

Integration of TB with PMTCTin Soweto, South Africa

• 3,970 pregnant women were screened for TB at ANC clinics between 12/08 to 8/09

• 36% HIV-infected• TB prevalence– HIV-infected: 696 per 100,000– HIV-uninfected: 200 per 100,000

Reference: Gounder et al. CROI 2010. Session 180, Abstract 900.

Global GoalsIndicator Stop TB Targets

for 2007Progress by 2007

% of SSM+ TB detected 68% for 2007, 78% for 2010

63%

% of all TB detected 70% 56%

% SSM+ TB cured 85% 78% DOTS(23% non-DOTS)

# TB cases worldwide(prevalence)

7.8 million by 2015

13.7 million

# TB deaths worldwide 750,000 by 2015 1.8 million

% TB patients tested for HIV 56% for 2007 16%

# TB/HIV patients receiving co-trimoxazole 600,000 200,000

% TB/HIV patients receiving ART 30% 34%

% HIV patients screened for TB 72% 2.2%

#HIV patients receiving isoniazid preventive therapy 1.5 million 30,000

Reference: WHO Global TB Control Report 2009. WHO Stop TB. The Global Plan to Stop TB -- 2006-2015. 2006.

GHI Consultation Document not Consistent with Lantos-Hyde Targets

Indicator Lantos-Hyde Target 2009-2013

GHI Targets 2009-2014

# new TB patients receiving treatment 4.5 million 2.6 million

# new MDR patients diagnosed, receiving treatment 90,000 57,200

Particularly poor delivery of TB-related interventions by HIV programs

• TB screening results in earlier detection of TB:– ↓ morbidity and mortality attributable to TB– ↓ duration of infectiousness– ↓ transmission of TB (and thus also part of infection control)

• Isoniazid preventive therapy– 50-70% reduction in mortality– Reduces risk of TB among both patients receiving and not

receiving ART• Infection control

– Administrative controls: triage, cough hygiene, reduce time spent in health facilities, occupational health

– Environmental controls: ventilation, UV germicidal irradiation– Personal protective equipment

References: Innes C. CROI TB/HIV Satellite Session. 2/16/2010. Samandari T. CROI TB/HIV Satellite Session. 2/16/2010. Golub JE et al. AIDS. 2009;23:631-6. Golub JE et al. AIDS. 2007;21:1441-8.

USG funding for Global HIV/AIDS and TB(millions of dollars)

FY 2009 Enacted

ObamaFY 2010

FY 2010 Enacted

ObamaFY 2011

% Change FY 2010 to

Proposed FY 2011

Requests from

Global Health

Coalitions

IOM Recommendation

by 2012

Global AIDS $5,159 $5,259 $5,359 $5,500 2.6% $7,250 $7,800*

Global Fund

$600 $900 $1,050 $1,000 -4.7% $1,750

USAID TB $163 $173 $225 $230 2.2% $650 $800

PEPFARTB-HIV**

$150 -- $160 -- -- -- --

CDC TB $143 $144 $144 $143 -7% $220 --

NIH TB $189 -- $226 $215 -4.8% $320 --

*Combined bilateral Global AIDS and Global Fund spending. Reference: Institute of Medicine. Recommendations for the U.S. Government. May 2009.** TB-HIV funding portions of PEPFAR, not additional.

Thanks to…

• Sen. Sherrod Brown• Sen. Barbara Boxer• Sen. Johnny Isakson• Sen. Dick Durbin• Sen. Robert Casey

• Sen. Frank Lautenberg• Sen. Benjamin Cardin• Sen. Kirsten Gillibrand• Sen. Edward Kaufman