World Bank, October 5, 2005

Tackling TB in the HIV era: implications for policy dialogue

and operations

Paul Nunn5 October 2005

" We can’t fight AIDS unless we do much more to fight TB as well "

Nelson Mandela

Bangkok, July 2004

Contents

• Current status of TB and HIV epidemics, focus on Africa

• The policy response

• Progress and operational issues

• Political and partnership commitments

• Conclusions

Current status of TB and HIV epidemics, focus on Africa

TB incidence rate

1990

2005

No estimate

< 50

50-100

100-200

200-300

300 and more

Stop TB DepartmentStop TB Department

Current Global Status

• 8.8 million new cases of TB in 2003 – 7.6% of total cases HIV+ (674 000) = 12% of

adult cases

• TB notifications and estimated incidence stable or decreasing in 5 WHO regions, increasing in Africa, due to HIV

• Global estimated incidence grew 1%

• Global prevalence and mortality rates falling

TB cases have been rising in Africa and E Europe

0

100

200

300

400

500

1990 1992 1994 1996 1998 2000 2002 2004

Inci

den

ce r

ate

(/10

0K/y

r)

Africa - high HIV

Africa - low HIV

Eastern Europe

incidence falling

rise in incidence slowing

Epidemic in sub-Saharan Africa 1985−2003

0

5

10

15

20

25

30

1985198619871988198919901991199219931994199519961997199819992000200120022003

Mill

ions

0

5

10

15

20

25

30

% 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)

0

100

200

300

400

500

600

700

1980 1990 2000

TB

not

ifica

tion/

100k

0.00

0.05

0.10

0.15

HIV

pre

vale

nce

Nairobi

TB Trends in Africa, 1980-2003HIV driving the TB Epidemic

0

100

200

300

400

500

1980 1985 1990 1995 2000 2005

No

tifi

ca

tio

n r

ate

(a

ll f

orm

s)/

10

0k

ZimbabweKenyaMalawiUR TanzaniaCôte d'Ivoire

Global Tuberculosis Control. WHO Report 2005. WHO/HTM/TB/2005.349

TB/HIV in Africa – 2003

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

82%)

Rank Country Number Country Rate Rank Country Number Country Rate

1 S. Africa 77.8 Botswana 724 16 Rwanda 7.6 C. d'Ivoire 197

2 Ethiopia 59.2 Zimbabwe 501 17 B. Faso 6.5 Uganda 173

3 Nigeria 49.9 Lesotho 492 18 Burundi 6.4 Tanzania 155

4 Kenya 43.9 Swaziland 478 19 Ghana 6.0 Cameroon 147

5 India 41.4 Zambia 409 20 Thailand 5.6 B. Faso 132

6 Zimbabwe 29.2 Namibia 385 21 Botswana 5.5 Congo 128

7 Tanzania 25.2 S. Africa 333 22 CAR 4.9 Cambodia 126

8 DR Congo 22.6 Djibouti 325 23 Myanmar 4.9 Togo 113

9 Mozam. 21.5 Malawi 323 24 Lesotho 4.8 DR Congo 105

10 Zambia 18.9 Kenya 295 25 Haiti 3.7 Nigeria 96

11 Uganda 17.3 CAR 290 26 Angola 3.1 Haiti 94

12 Malawi 16.1 Mozam. 258 27 Namibia 3.1 Gabon 82

13 C. d'Ivoire 15.0 Burundi 228 28 China 2.9 Ghana 64

14 Cameroon 10.1 Rwanda 211 29 Togo 2.4 S. Leone 56

15 Cambodia 7.7 Ethiopia 209 30 USA 2.3 Angola 56

Countries ranked by a) Number: the number of TB cases attributable to HIV (thousands) and b) Rate: the number of TB cases attributable to HIV per 100,000 population. Above red line: 80% of total number; above blue line: 90% of total number

TB case fatality rates: AfricaHIV+ = 3.5 x HIV-

0

5

10

15

20

25

30

35

40

45B

FA

TAN

DR

C

ZA

M

CA

R

CD

I

KE

N

MA

L

MA

L

SA

F

SA

F

SA

F

DR

C

country

CF

R (

%)

HIV+

HIV-

all forms smear-positive

source: Ya Diul 2000

Epidemiological summary• TB coming under control everywhere except

Africa (and Eastern Europe)• HIV is the proximal cause in Africa• East and Southern Africa worst hit• Women more affected than men by TB/HIV• Mortality from TB rising with HIV• Most TB in Africa in HIV uninfected• Notwithstanding, TB control nearing 2005 targets• MDGs likely to be met, except in Africa and

Eastern Europe• Battleground for TB MDGs shifts towards Africa

The policy response

WHO-recommended Stop TB Strategy to Reach the 2015 MDGs

1. Pursuing quality DOTS expansion and enhancement• Political commitment • Case detection through bacteriology• Standardised treatment, with supervision and patient support• Effective drug supply system• Monitoring system and impact evaluation

Additional components from October 2005

2 Addressing TB/HIV and MDR-TB

3. Contributing to health system strengthening

4. Engaging all care providers

5. Empowering patients and communities 6. Enabling and promoting research

Reasons for failure:treatment outcomes are worst in

Africa and Europe

0 10 20 30 40

Africa

Americas

E Med

Europe

SE Asia

W Pacific

Percent of cohort

Died

Failed

Defaulted

Transfered

Not Evaluated

• Therefore DOTS alone is insufficient to control TB where HIV is high and rising

Additional options:TB/HIV Collaborative ActivitiesDecrease the burden of tuberculosis in people living with

HIV/AIDS• Establish intensified tuberculosis case-finding• Introduce isoniazid preventive therapy• Ensure tuberculosis infection control in health care and

congregate settingsDecrease the burden of HIV in tuberculosis patients• Provide HIV testing and counselling• Introduce HIV prevention methods• Introduce co-trimoxazole preventive therapy• Ensure HIV/AIDS care and support• Introduce antiretroviral therapyEstablish mechanisms for collaboration• Set up a coordinating body for TB/HIV activities • Conduct surveillance of HIV prevalence among tuberculosis

patients• Carry out joint TB/HIV planning• Conduct monitoring and evaluation

TB/HIV policy guidance - 2004

Interim policy M&E Surveillance ART

ProTEST lessons TBHIV Clinical HIV testing policy

Experience from ProTEST, Malawi, South Africa, Zambia etc

• TB/HIV collaboration possible and useful• Responds to huge unmet need• Filled a large policy void• Policy makers and managers convinced -> expansion• Involvement of all stakeholders critical• Additional staff essential • Technical support essential• More operational research/cultural understanding

required to increase adherence to preventive treatments

• Standard monitoring and evaluation tools needed• Joint TB/HIV work sets stage for ARVs

Progress and operational issues

GP2: cost by type of investment

DiagnosticUS$ 0.2 bn

DrugsUS$ 4.2 bn

Vaccines US$ 3.1 bn

ACSM US$ 3.2 bn

DOTS Expansion US$ 31 bn DOTS Plus

US$ 6.6 bn

TB/HIV US$ 7.7 bn

Total needs GP2: US$ 56 bn

5.5 bn

Global Plan to Stop TB II, 2006-2015

Cost by type of investment

Countries involved

• Making progress - Africa:– Botswana, Cote d'Ivoire, DRC, Ethiopia,

Kenya, Malawi, Rwanda, South Africa, Tanzania, Zambia

• Making progress elsewhere: – Brazil, Cambodia, Haiti, India, Thailand,

Central America

• Starting: – China, Indonesia, Mozambique, Namibia,

Nigeria, Uganda, Vietnam

Malawi

• In year to July 2004, 27% TB patients received HIV test – 67% HIV +ve

• Of those positive, 90+% received CPT

• Of 22973 patients ever started on ART up to July 2005, 3081 (13%) due to TB

• Of 5696 patients on ART in Q2 2005, 908 (16%) due to TB – 13% of all TB patients registered in Q2

Comprehensive HIV treatment including DOT- TB/ART is feasible even in the poorest of settings (PIH Haiti)

TB/HIV Expansion progress – Sept 2004• Funding commitment is no longer the bottleneck• PEPFAR increasing TB/HIV element in 2006

country operational plans – ART targets cannot be met without involving TB programmes

• TB/HIV emphasised in GFATM R5 – TB/HIV in: – 17/22 approved TB proposals– 6/25 approved HIV proposals

• TB/HIV activities in most regions • 13/33 countries surveyed have coordination

mechanism, 50% doing joint planning• Large human resource gap• Recording and reporting gap at peripheral level

TB/HIV Diagnosis and ReferralTB Control Program HIV Control Program

TB Suspect HIV Suspect

DOTS HIV/AIDS Care

TB Unit HIV testing centre

No TB Active TB HIV Positive HIV negative

TB Health Education

HIV Prevention

Which model of integration ?

TB HIV/AIDS

TB + ARV HIV/AIDS TB TB/HIV

Infectious disease chronic care unit

TB patients

ARV follow-up

One stop service for TB-HIV co-infected

Political and partnership commitments• Commission for Africa, G8, UN World Summit,

African Union• Maputo declaration of TB: an emergency in

Africa• Stop TB Partnership "blueprint" for action in

Africa and WHO/AFRO lead in planning• TB/HIV Working Group• PEPFAR, GFATM and role for increasing WB

MAP collaboration

Political and partnership issues

• TB is perceived as "just another HIV issue"

• TB:HIV cultural differences– Treatment vs prevention– Impact of emphasis on HIV/AIDS treatment

• Institutional divides– National TB Programmes, National AIDS

Control Programmes, and National AIDS Commissions, CCMs

Conclusions• WHO TB/HIV collaborative activity policy

being implemented• Fast multiplication of activities but demand

outstripping supply• Urgent need for monitoring and impact

evaluation• Funds OK for now - human resources

insufficient• Debate on operational issues and country by

country resolution of constraints needed• Advocacy, political support, country

assistance and close collaboration needed

Mandela urges action to fight TBBy Chris Hogg BBC Bangkok

Mandela sounds alarm on TB "death sentence" in AIDS war By Darren Schuettler

BANGKOK (Reuters) – The global war on AIDS could be lost if the world ignores tuberculosis, often a "death sentence" for people infected with HIV, former South African president Nelson Mandela said on Thursday.

BANGKOK: by Lawrence K. Altman –

Nelson Mandela came to the 15th International AIDS Conference here Thursday to lend his prestige to the battles against tuberculosis and AIDS, two deadly diseases that are intricately linked.

Distribution of PCP, Toxoplasmosis and Tuberculosis in Reported AIDS Cases to MOH (Brazil, 1981-2001)

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1985 1990 1995 2000 2005

Nu

mb

er o

f C

ases

PCP Toxoplasmosis Disseminated TB Pulmonary TB

Source: MOH, 2002Marco Victoria, DOH Brazil