TB/HIV: Global Progress in Implementation and Challenges

1. TB/HIV: Global Progress in Implementation and Challenges Diane V. Havlir, MD University of California, San Francisco, CA Diane V. Havlir, MD University of California, San Francisco Chair, HIV/TB Working Group of the STOP TB Partnership

2. Overview • Progress over the last year • Core Group Activities • Global Reports • Evaluation of Working Group Activities • What next for the Working Group?

3. Mission of the HIV/TB Working Group Reduce global burden of HIV/TB through effective collaboration between TB and HIV communities, establishing policies, targets, monitoring and evaluations for evidence based collaborative HIV/TB activities

4. 2008-2009 Goals • Catalyze nationwide expansion of HIV/TB activities in more countries, with regional focus on Asia Pacific and Africa • Promote implementation of Three Is for HIV/TB by all HIV stakeholders • Improve and harmonize monitoring & evaluation across UN agencies and partners • Raise research interest and investment • Raise global visibility of HIV/TB • Increase HIV civil society response to TB/HIV

5. Progress since last meeting • 30/33 action items from 14th Core Group meeting completed - 3/33 not completed • Highlights of activity • TB/HIV Research priorities discussed by HIV experts • Highlighted by influential leaders • Harmonization of M&E indicators for TB/HIV • Meta-analysis of ICF screening completed • TB/HIV visibility in political arena (maintenance of resources in financially critical time) and presence at HIV meetings • TB/HIV key priority for UNAIDS framework for action 2009-2011

6. Latest global TB estimates Estimated number of cases Estimated number of deaths All forms of TB Greatest number of cases in Asia; greatest rates per capita in Africa 9.27 million (139 per 100,000) 1.77 million (27 per 100,000) Multidrug-resistant TB (MDR-TB) 511,000 ~150,000 Extensively drug-resistant TB (XDR-TB) ~30,000 ~50,000 HIV-associated TB 500,000 1.4 million

7. The WHO 12 points policy package A. Establish the mechanism for collaboration 1. TB/HIV coordinating bodies 2. HIV surveillance among TB patient 3. TB/HIV planning 4. TB/HIV monitoring and evaluation B. To decrease the burden of TB in PLWHA 5. Intensified TB case finding 6. Isoniazid preventive therapy 7. TB infection control in health care and other settings Joint HIV and TB HIV programme 6A ANTIRETROVRAL THERAPY C. To decrease the burden of HIV in TB patients 8. HIV testing and counselling 9. HIV preventive methods 10. Cotrimoxazole preventive therapy 11. HIV/AIDS care and support 12. Antiretroviral therapy to TB patients. TB programme

8. HIV Testing for Notified TB Patients 2008 2005 2007 2006 11% 22% 37% 48% Proportion of TB patients tested for HIV Key HIV testing is becoming a standard care for all TB patients No reported activity < 15% 15 to 50% 51 to 74% More than 75% The map for 2008 is preliminary and does not show actual colours of implementation in all countries

9. HIV testing of TB Patients in India

10. Global Implementation of key HIV/TB Activities Global implementation of key TB/HIV activities 2006-2008 Data for 2008 is preliminary and does not include data from European region

11. TB screening, treatment and IPT 2002-2008 By 2008, 1 out of 4 estimated HIV positive TB patients were identified and put on TB treatment Data for 2008 is preliminary and does not include data from European region

12. 2. What is the impact of the working group? • Significant Progress • Some Progress • Little Progress

13. Significant Progress (1) • HIV/TB Collaborative Activities at Country Level • Implementation • HIV testing • TB screening (algorithms/clinical screening) • Monitoring and Evaluation • New HIV/TB estimates • New and harmonized indicators • Harmonized monitoring

14. Significant Progress (2) • Visibility/ Presence of HIV/TB at the international and regional level • International AIDS and TB union Conferences Global Fund for HIV/TB, Malaria • PEPFAR step up funding for TB/HIV • First protest/march HIV/TB • Regional: ICCAP and UNAIDS Meeting in Dakar • Catalyst of HIV/TB Research Agenda • Meetings/Recruitment of young investigators • New Report on Research Priorities

15. Some Progress • Infection Control • New guidelines • Renewed interest in public health/research community • Uptake and traction of research agenda not clear • Diagnostics • Linkages with FIND • Roll out of TB testing for HIV population unclear • Reporting • Made easier with harmonization • Still under reporting of HIV/TB activities

16. Little Progress • MDR/XDR • Recognition of the problem, but scope not clear • Treatment outcomes not clear • New drugs in pipeline, not yet readily accessible to HIV population • Lack of linkages with incarcerated populations

17. 3. THE HIV/TB Working Group - What Next? 2003-2006 2006-2009 2010-2013 LETS GET SERIOUS SET THE PLAN IN MOTION Heighten visibility Push implementation Improve monitoring Enhance research SET THE FRAMEWORK HIV/TB Guidelines Community Activism Research priorities Bring in HIV REDUCE TB BURDEN IN HIV POPULATION REDUCE HIV/TB DEATHS

18. What are some high impact areas? • TB prevention– Widespread ART and IPT • We are not utilizing these powerful tools and could work with HIV centers • TB diagnostics– Roll out of new technologies • We are only identifying and treating ¼ of cases • Integration of HIV and TB services • Remains a weak link in addressing many implementation goals

19. Should we focus on HIV centers? • High capability to implement TB PREVENTION activities • Low Capability for TB DIAGNOSIS • Moderate capability to optimize TB TREATMENT

20. ART– STATUS OF THE ROLL OUT 4. Global HIV treatment--Progress WHO/UNAIDS 2009 Report

21. Reduction in TB case at community level associated with ART HIV infected “off ART” TB Rates ART coverage HIV infected “on ART” Courtesy of Middelkoop, IAS, Late Breaker,2009

22. Mortality and TB incident cases lower in early vs standard group Mortality decreased by 75% TB decreased by 50% Fitzgerald, ICAAC, 2009

23. Adult prevalence of HIV and population notification rate of TB Zimbabwe Botswana HIV TB HIV TB HIV Brian Williams, et al. submitted

24. TB in South Africa if nothing changes Brian Williams, et al. submitted

25. HIV-negative;including those on ART;including HIV-positive not on ART; total 350/mL 200/mL 500/mL Immediately Impact on TB of testing people in South Africa once a year for HIV and starting them on ART at different CD4 levels.

26. Starting ART less than five years after infection will rapidly cut the incidence of TB by about 60% to 70%. IPT could given an bigger initial reduction. What happens after that depends on what happens to HIV.

27. Should we focus on TB treatment centers? • Growing infrastructure to diagnose HIV • Little infrastructure to treat HIV • Some notable exceptions – Africa

28. Mismatch of TB treatment and HIV testing and ART services in eight countries, 2007 For every ART facility there are 5 TB and 3 HIV testing facilities respectively!

29. Should we focus on integration of HIV and TB services? • In theory, this makes great sense • Some successful models have emerged • One size does not fit all • Huge challenges • Infection control issues, including health workers • Separate administration, management, budget • Manpower shortage

30. Summary • HIV/TB remains a global health care crises • The Core Group has set a policy framework, pushed these policies in action, raised visibility and improved monitoring of HIV/TB • Important areas such as MDR/XDR remain huge threats • The core group must define priorities for the coming years that are likely to yield the highest impact

31. DISCUSSION - What Next? 2003-2006 2006-2009 2010-2013 LETS GET SERIOUS SET THE PLAN IN MOTION Heighten visibility Push implementation Improve monitoring Enhance research SET THE FRAMEWORK HIV/TB Guidelines Community Activism ? Research REDUCE TB BURDEN IN HIV POPULATION REDUCE HIV/TB DEATHS