Global Strategies to Stop TB/HIV: Summaries and Recommendations

1. Rapporteur’ s presentation Fabio Scano GLOBAL PARTNERSHIP TO STOP TB

2. TB/HIV Interim Policy Conclusions • Amidst calls for minor changes, there is wide support for the TB/HIV Interim Policy among WG participants • Interim Policy clearly fills gap between existing TB/HIV Strategic Framework, TB/HIV Guidelines and what should be done and when to do it • Interim Policy is add-on for both TB and AIDS programs for TB/HIV issues that have not adequately been addressed • There is consensus among WG Meeting participants about the need to quickly publish and disseminate the Interim Policy

3. TB/HIV Interim Policy Recommendations • WHO should consider to include technical TB/HIV aspects in the Interim Policy • The Interim Policy should include well defined criteria that guide countries in the implementation of TB/HIV activities • WHO should fast-track the publication and dissemination of the Interim TB/HIV Policy • WHO should ensure that the Interim Policy is effectively “marketed” at country level

4. HIV surveillance among TB patientsConclusions • The WG participants welcome the 2nd edition of the Guidelines for HIV surveillance among TB patients • The WG participants acknowledge that the HIV surveillance guidelines address the different situations of underlying HIV epidemic state and tuberculosis burden • The paragraph on anonymous unlinked testing does not reflect most recent views on the use of this method • WG participants identify the need for easy, cheap and effective HIV tests, such as sputum tests

5. HIV surveillance among TB patients Recommendations • WHO should consider revising the paragraph on anonymous unlinked testing to reflect most recent views on the use of this method • WHO should finalize the Guidelines for HIV surveillance among TB patients and publish and disseminate among member countries • WHO should encourage and facilitate research on testing of sputum samples for HIV

6. Public Health Approach to ARTConclusions • The WG welcomes the call for HIV program to link up with other programs in its effort to increase access to ART • The WG acknowledges the strong need to strengthen the human resource capacity, especially nurses, to increase the options for delivery of ART • Community partnerships are important tools to bring about behavioural change and more effective utilisation of HIV/AIDS care

7. IMAI • Different modules of IMAI have presented to WG mtg’s participants. • How this document builds on currents documents has been discussed. • Usefulness for HCW has been acknoledeged

8. Anti-retroviral treatment for TB patients • Plan to develop a useful document for national managers/HCWs in order to deal with ART in TB patients • Selected topica: when to start ART, drug interaction and immunoreconstituion inflammatory syndrome, adherence to treatment, clinical management, research agenda • Time table with selection of writing committee by August 2003 and finalization of the “chapter” by March 2004.

9. Anti-retroviral treatment for TB patients II • Conclusions/recommendations: • Practical guidelines for ART management in TB patients are needed: many countries still to develop their own. • Evidence not fully available but need to anwser some issues: adherence and case management • Nutritional support, cotrimoxazole prophylaxis, IPT should be considered in these guidelines

10. HIV SURVAILLANCE Conclusions • -HIV surveillance among TB+ patients is feasible (Cambodia) • The methodology needs to be adapted and reflect regional aspects (HIV/TB epidemic level, pre/existing TB/HIV health care and surveillance system, traditional and culture differences) • -HIV surveillance among TB+ patients is essential for programming preventive activities at all levels (international, national, regional and local). • -HIV surveillance among TB+ patients, as well other TB/HIV activities, needs to be better co-ordinated between NTP and NAP.

11. Monitoring and Evaluation • The draft M&E guideline was distributed and its structure and content was briefly presented • Recommendation: • The M&E tool to be developed should be consistence with existing M& E tools of the general health services. One possible area to explore is using the existing HIV and/or NTP tools. The policy document should address this.

12. Prevention of TB recurrence • 1. Use RH in continuation phase (CP) • 2. Extend duration of CP in HIV+ patients • 3. Give post-treatment isoniazid to HIV+ve patients who complete anti-TB treatment • 4. Treat HIV+ve TB patients with HAART

13. CONCLUSIONS AND RECOMMENDATIONS Country TB programmes should be able to determine true burden of recurrent TB If burden is high, then determine which of the four options is most cost-effective, feasible and least dangerous to do. Global policy needed. Need of clinical studies / operational research in the prolongation of regimens.

14. CPT in Malawi • · Conclusions and recommendations : • Reduces mortality in HIV+ individuals in resource poor countries, in absence of HAART. • Represents an opportunity for integrating HIV/TB care. • Is an essential first step towards establishing comprehensive HIV care. • Need of a revision of WHO guidelines, specifically for AFRO. • Countries should consider practical issues, before to adopt it as national guidelines. • Need for further studies to evaluate the protection of CPT for Malaria in HIV + patients.

15. VCT for TB patients • Recommendations • Right to know HIV status should ensure the right to access comprehensive care and support services. • Scaling up VCT needs equal preparation of the health services and the community to address the increasing demand and arising stigma and discrimination respectively. • .HIV testing and counselling must be implemented in a broader and radically larger scale in the face of the “3 by 5” plan for ARV. • There is a need for addressing the human resources issues in the scaling up of VCT.

16. Regional responses: Middle and Low Burden Countries Mechanism for implementing TB/HIV interventions • Mechanism for partnership between health services and PHA groups such as “day care center (DCC)” should be developed to provide HIV/AIDS care package including TB services and TB/HIV referral. • The level where DCC will be developed is to be determined according to the local HIV prevalence (e.g. Village level in very high prevalence area, National level in very low prevalence country). • Maximal precautions should be done to prevent TB transmission among DCC members.

17. Regional responses: Middle and Low Burden Countries Determination of responsibilities between two programs • NAP should be responsible for referring PHA to TB diagnosis. • NTP should be responsible for referring TB cases to VCT Role of WHO to assist countries • To identify magnitude of TB/HIV in the country • To develop national TB/HIV framework and guidelines • To organize joint TB/HIV meeting for national program managers and joint training for mid-level managers • To coordinate external funding in support of agreed national TB/HIV framework

18. High burden countries • Facts, action, vision, challenges and opportunities. Five questions: • Is a regional response relevant? Yes • HIV/TB collaboration: constraints? solutions? Several constraints, all can be solved. • Interventions: how should they be prioritised? Facility level and programme level. • What organizational framework is needed? Separate except at the facility/delivery level. • How can the working group strengthen a regional response? Training and mobilisation. • Regional Response • Important because of the very high burden of both diseases in Africa. • But substantial variations within Africa. • Need to interact with national governments and regional groups: OAU;SADC; NEPAD. • Provide technical support to national programmes. • Collaboration • Not clear what we mean. Develop the concept. • Conceptual/structural differences (vertical v. horizontal). Joint planning. • Operational gaps DOTS v. VCT; cure v. behaviour change. Referral mechanisms. • Resources. Share infrastructure, drugs, people, ideas

19. Interventions • Access to ARVs with a simple standardized regimen. • TB patients: access to VCT; People with HIV: treatment for TB. • Need more trained people! • Framework • Allow country specific decisions. • Situational analysis. Joint planning. • One director—two programmes. Two programmes—one co-ordinator. Stay separate down to the facility level. • Mobilise political support (governments). • Commitment to working together is the key. • Working group • Train a pool of local consultants. • Raise money and mobilise resources. • Support policy development. • Develop a regional strategy.