Presentation for Second Meeting of the Global TB/HIV Working Group

1. SUPPORTING COUNTRIES IMPLEMENT COLLABORATIVE TB &HIV/AIDS ACTIVITIES: THE CASE OF THE AFRICAN REGION Presentation for Second Meeting of the Global TB/HIV Working Group 14-16 June, 2002. Durban South Africa Wilfred C. Nkhoma FOR WHO/AFRO TB & AIDS UNITS

2. OUTLINE OF PRESENTATION • Re-stating the dual epidemic • Current responses to the dual epidemic • The Concept of Phased implementation of collaborative activities • Conclusion

3. Re-stating the dual epidemic • Conclusive global and Regional evidence of increased TB incidence among populations with high HIV prevalence since the advent of HIV/AIDS : HIV prevalence consistently higher among TB patients than in the general population; early diagnosis and treatment of TB in PLWHAs associated with improved quality of life and conversely, effective HIV prevention and care leading to reduced incidence of TB related morbidity and mortality • The African Region is disproportionately affected by the TB &HIV/AIDS dual epidemic

4. Trend of TB notification rates in selected High or rising HIV prevalence Countries in Africa 1990-1998

5. Trend of TB notification rates in selected Low HIV prevalence countries in Africa 1990-1998

6. New HIV Infections by Region 1980-1999

7. Current responses to the dual epidemic (1) 1. Traditional vertical disease specific responses Responses undermined by: • Weak programmes and health infrastructure • Insufficient coverage with effective control strategies • Scarceresources (technical, logistical, financial etc) • Unco-ordinated efforts to cater for common clients • Stigma issues Etc, etc

8. Current responses to the dual epidemic (2) 2. Piloting Integrated service delivery e.g ProTEST Projects [Malawi, South Africa & Zambia] Associated characteristics: • Mostly designed with the sole purpose of allowing lessons to be learned and experiences to be gained • Limited coverage and scope • Often undertaken in ways that can not be be replicated across a whole country (e.g implemented with the support of an unsustainable level of human and financial resources). • Tendency to be implemented outside general health service structures and ownership (commonly associated with/reflected institutional, or agency preferences to implement only certain activities) Piloting has allowed some lessons to be learned upon which to build large scale implementation of collaborative TB/HIV/AIDS activities.

9. Countrywide implementation by increment: Phased implementation of collaborative TB/HIV/AIDS activities: • Effective TB & HIV/AIDS control are tasks for a life time and must be undertaken on a full scale basis and collaboratively for significant impacts • Idea is to plan for a deliberate full-scale undertaking but phasing in time and scope so as to break down complex implementation issues into simple manageable tasks and stages • More often than not, PHASING as opposed to PILOTING, allows lessons to be learned and experiences to be gained during the implementation process within the general health service delivery system. More importantly, it allows sufficient technical and logistic capacity to be developed at the operational level.

10. The approach to Phased implementation of Collaborative TB/HIV/AIDS activities • Documentation and dissemination of lessons from pilot projects • Development of plans of action for phased implementation of collaborative TB/HIV/AIDS activities as part of national programs (e.g Regional collaboration initiatives, development of technical networks, development of regional tools, Nairobi workshop for 8 Anglophone countries and planned workshop for selected Francophone countries in the African Region etc) • Focus on collaborative delivery of a package of proven TB and HIV/AIDS prevention, care and support interventions • Development of technical capacity and mobilization of financial and other resources for implementation of the package of collaborative activities • Monitoring and evaluation • Operational research (for performance improvement)

11. Prevention of HIV infection [counseling and education, IEC, condoms, STI treatment, PMTCT, safe blood initiatives, etc] VCT for HIV HIV/AIDS care and social support Diagnosis and management of other HIV/AIDS opportunistic infections Early diagnosis and effective treatment of TB based on the DOTS strategy Capacity building (infrastructural, human etc) Surveillance, monitoring and evaluation TB preventive therapy Preventive therapy for other common bacterial OIs in PLWHAs ARVs for HIV/AIDS Community and home based care initiatives for TB & HIV/AIDS Operational Research CRITICAL TB & HIV/AIDS INTERVENTIONS FOR PHASED IMPLEMENTATION OF COLLABORATIVE ACTIVITIES

12. Expected outcomes • Increased TB & HIV/AIDS detection and access to care and support • Improved effectiveness and quality of care • Improved efficiency of health services • Better equity in TB & HIV/AIDS services delivery (allocative and technical equity) • Applicability in all countries and settings • Any contact with health services as an entry point for accessing TB & HIV/AIDS prevention, care and support services • Standard disease specific outcomes can be used to monitor and evaluate effectiveness and cost-effectiveness of the key interventions

13. Conclusions • Effective TB & HIV/AIDS control are tasks for a life time and must be undertaken on a full scale basis in a collaborative manner. • Implementation of disease specific interventions for TB & HIV/AIDS without regard for the synergistic interaction between the two infections has not brought about significant impacts on the burden of the two diseases • Current responses to the TB and HIV/AIDS epidemics, and specific piloting of collaborative implementation of TB/HIV/AIDS activities have provided some lessons upon which to plan and build large scale implementation of collaborative activities. • Phased implementation of activities in time and scope is being actively promoted in the African Region as it has the added advantage of allowing lessons to be learned in the implementation process and sufficient capacity to be developed at the operational level. It also allows complex tasks to be broken down into manageable stages