Learning without thinking is labour lost; thinking without learning is perilous Confucius VI BC

1. The importance of TB and HIV programme collaboration and expanding the scope of collaboration for the future.20 min.George LothWHO/HIV/SRM

2. Learning without thinking is labour lost;thinking without learning is perilousConfucius VI BC

3. UNGASS Reduction of HIV prevalence by 25% in most affected countries Three million people in developing countries on HIV/AIDS treatment by 20005

4. Priorities ? • Accelerating Access Initiative June 2002 • Scaling Up ARV therapy in limited settings June 2002 • A commitment to Action for Expanded Access to HIV/AIDS treatment HIV December 2002

5. Increasing Access to HIV testing and counselling.From VCT to TC

6. Estimated Cost for T & C • PMTCT : 46 million • Treatment : 37 million • Prevention : 101.1 million • Grand total : 184.1 millionNew data

7. Analysis Inputs: Costs • Per Client Cost Estimates: • Health System Enhancements: $5 ($1-$9) • Pretest Counseling: $2 ($1-$3) • HIV Testing & Posttest Counseling –$6 ($3-$9) • NVP –for mother and infant - $4.82 (+/- 25%) • HIV Treatment for infants - $281($0-$562) • Note – cost estimates may be conservative (lower than actual). Opted for lower cost estimates until better data is available.

8. Distribution of Cost Components

9. Inputs: Proportion of Prenatal Women who have at Least 1 ANC Visit

10. Inputs: Proportion of Women Receiving Pretest Counseling Data from UNICEF

11. Outcomes: % of HIV+ Mothers Reached and Treated with ARV

12. Target for ARV treatment 3 million on ART by 2005 • by 2007, 45% requiring ART ,receive it (CMH). • 40 million PWHAs in resource-limited setting • 15% clinically sick enough to need ART Aspirational goal; without capacity development particularly human resources we will fail !

14. A Public Health approach • Able to scale up ART to meet the needs of people living with HIV/AIDS in resource-limited settings • standardisation and simplification of ARV regimes to support broad and efficient implementation, and accessible treatment programmes • evidence-based recommendations aiming to avoid substandard or sub-optimal treatment or the creation of the potential for the emergence of drug resistant virus

15. When to start therapy

16. First line regimens

17. Second line regimens

18. Entry and Monitoring • Must have: clinical assessment, HIV testing, and haemoglobin t • Additional basic testing: white blood cell count and differential, LFTs, creatinine and/or blood urea nitrogen, serum glucose, and pregnancy tests for women. • Desirable tests include bilirubin, amylase and serum lipids. • CD4 cell determinations are very desirable and every effort should be made to make these widely available. • Viral load testing is currently considered optional. Increasing recognition that access to laboratory monitoring will be a major access bottleneck

19. Underlying considerations • Potent regimens (including at least 3 drugs) to prevent resistance and maximise benefit • Standardisation to allow use in settings where HIV/AIDS specialists and tests to monitor treatment are not readily available and facilitate continuous availability of the drugs • Recommendations on best available evidence • Incorporate flexibility in regimens to manage toxicity • Include specific groups - children, pregnancy, IDUs and co-pathology • aim for standard first then second-line regimes

20. ART in HIV-positive patient with TB Not ideal to prescribe seven potentially toxic drugs together Many will be diagnosed with HIV when present with TB • Recommend that TB patients complete TB therapyunless a high risk of HIV progression/death (CD4; dissemination) • Try to complete induction treatment if possible without starting ARVs • If clinically necessary treat both diseases together

21. ART in HIV-positive patient with TB CD4 below 50 and/or disseminated TB • dual treatment indicated • ZDV/3TC backbone; ABC or EFV or SQV/r preferred; CD4 between 50 - 200 or TLC < 1000-1200 • complete 2 months of induction therapy • same regime considerations Pulmonary TB and CD4 > 200 or TLC > 1000-1200 • Treat TB • Monitor clinical status; start ARV if necessary • Start “standard” ART after therapy when indicated

22. ART in HIV-positive patients with TB • Almost a data free-zone … • need to review evidence and experience offirst wave of TB-HIV treatment centres ASAP • revise guidelines accordingly “In this rapidly evolving field, WHO recognises that these recommendations will need to be updated on a regular basis”

23. Conclusions • Potentially huge additional TB-HIV disease burden which is currently ignored …... • Unclear of extent and what to do • If not addressed TB will continue as biggest killer in HIV (and we fail with UNGASS) • TB is biggest opportunity for immediately improving outcome and survival for HIV-TB • Go for a positive not fatalistic message

24. The further challenge Urgent need for collaboration ! Patient with unknown HIV and TB status and unknown patient • Improvement of Surveillance (SGS and DHS+). • Strengthening PHC / District HC on TB and HIV issues (undiagnosed). • Support in high-burden countries acute medical services.

25. Not every thing that counts can be counted and everything that can be counted counts.Albert Einstein