World Bank, October 5, 2005 Tackling TB in the HIV era: implications for policy dialogue and...
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Transcript of World Bank, October 5, 2005 Tackling TB in the HIV era: implications for policy dialogue and...
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