TB and HIV Management in High HIV Prevalence Settings: the Policy Perspective

1. TB and HIV Management in High HIV Prevalence Settings: the Policy Perspective Kevin M. De Cock Center for Global Health Centers for Disease Control and Prevention

2. Integration Blues Why integrate? • Improved health outcomes • Better service performance • Increased efficiency • Cost savings • Patient/client convenience Potential adverse effects: • Erosion of technical quality • Loss of accountability • Lowering of morale • Nosocomial infection Two, four, six, eight, Time to go and integrate…. Tom Lehrer

3. Cases in millions 10 8 6 4 2 0 1990 1994 1998 2002 2006 Policy, Regulations and Guidelines • Policy A course of action (or inaction) usually taken by authorities with regard to a particular set of issues The “what” and “why” • Regulations and Guidelines Tools to implement a particular policy choice The “how”, “when” and “where”

4. Factors that affect health Smallest Impact Largest Impact Examples Condom use Counseling & Education Tuberculosis treatment Clinical Interventions Male circumcision Long-lasting Protective Interventions Functioning public health system, universal access Changing the Context to make individuals’ default decisions healthy Poverty, education, housing, inequality Socioeconomic Factors

5. Policy and the Evidence Base Evidence Values Human rights Social justice Dignity Ethics and morals Politics “The duty to protect” • Science should drive public health policy • “Evidence-based” or “evidence-informed”? • “Everyone is entitled to his own opinion, but not to his own data”

6. Which model of collaboration ? TB HIV/AIDS TB AIDS TB AIDS TB/AIDS Separate TB/ HIV patients referral Partial Some mixing Full One stop service for TB-HIV co-infected GH Friedland, MD

7. Current and Optimal TB and HIV Program Paradigms Current TB and HIV Programs Paradigm Optimal TB and HIV Programs Paradigm National HIV Program National TB Program National HIV Program National TB Program Communication Collaboration HIV Services VCT OI Px Antiretrovirals Adherence Support Communication and Collaboration HIV Services PITC OI Px Antiretrovirals Adherence Support TB Services Sputum collection DOT Treatment Support Contact Tracing LTBI Treatment TB Services Sputum collection DOT Treatment Support Contact Tracing LTBI Treatment GH Friedland, MD

8. From DOTS to the Stop TB Strategy High quality DOTS expansion TB/HIV, MDR-TB, vulnerable populations Health systems strengthening, primary health care Engage all care providers Empower TB patients, communities through partnerships Research

9. Policy and Practice TB Treatment Outcome • Cured • Treatment completed • Died • Treatment failure • Transferred out • Default

10. Policy on collaborative TB/HIV activities A WHO Document, 2004 A. Establish NTP-NACP collaborative mechanisms • Set up coordinating bodies for effective TB/HIV activities at all levels • Conduct surveillance of HIV prevalence among TB cases • Carry out joint TB/HIV planning • Monitor and evaluate collaborative TB/HIV activities B. Decrease burden of TB among PLHIV (the "Three I's") • Establish intensified TB case finding • Introduce INH preventive therapy • Ensure TB infection control in health care and congregate settings C. Decrease burden of HIV among TB patients • Provide HIV testing and counselling • Introduce HIV prevention methods • Introduce co-trimoxazole preventive therapy • Ensure HIV/AIDS care and support • Introduce ARVs World Health Organization

11. Lancet 2006; 368: 1575-80

12. Involve community Develop IC plan Safe sputum collection Cough hygiene Triage TB suspects Rapid diagnosis and treatment Improve room ventilation Protect health care workers Capacity building Monitor IC practices TB Infection Control – 10 Steps

13. Science 2010; 328:856

14. Game Changers • Discontinuous, radical innovations completely changing the way something is done, thought about, or made. Examples: - Cell phones - HIV/AIDS - Laptop computers - Antiretrovirals - Internet - PEPFAR - 9/11

15. Transmission occurs only from HIV+ persons Viral load is strongest risk factor for transmission ART can lower viral load to undetectable levels PMTCT offers proof of concept of reduced transmission with ART Discordant couple studies are supportive Discordant Couple Studies Reynolds S et al. 16th CROI, Montreal, Feb 2009 Abs. 52a Marcelin A et al. 16th CROI, Montreal, Feb 2009 Abs. 51 Donnell D et al. Lancet 2010;375:2092-8 Antiretroviral Therapy for HIV Prevention

16. Antiretroviral therapy for HIV prevention Mathematical model of universal HIV testing annually with immediate ART for HIV+ in southern African epidemic 95% reduction in HIV incidence in 10 years Prevalence <1% in medium term Major reduction in mortality Cost-saving in medium term Lancet 2009;373:48-57.

17. Trial of 6 vs 36 mos of isoniazid preventive therapy, Botswana (Samandari T et al, 2009)

18. TB/HIV in High HIV Prevalence Settings What will it take? • Evidence and data • Innovative and clear thinking • Judgment - balancing risk and “reckless caution” • Leadership • Policy, linked to research, implementation and advocacy