Tuberculosis TB

1. OSI-TAG TB/HIV Orientation Workshop, Sept 25-28,2006, Istanbul, Turkey Interim Policy on Collaborative TB/HIVActivities Haileyesus Getahun Stop TB Department WHO

2. Tuberculosis (TB) • Infectious respiratory disease caused by Mycobacterium tuberculosis • Clinical symptoms include: cough (> 2 weeks), weight loss and night sweats • Latent infection: bacteria remain in the lungs • Curable disease (6-8 months treatment) • DOTS is the TB control strategy

3. HIV fuels TB in three ways • Promotes progression to active TB disease • Reactivates latent TB infection • Increases rate of TB recurrence

4. Estimated tuberculosis cases per 100,000 population in 2004

5. TB/HIV 14 million TB/HIV infection HIV infection TB infection 42 Million HIV/TB 2 Billion

6. TB in PLHIV • 750,000 PLHIV develop TB every year • 11% of total deaths among PLHIV • 250,000 PLHIV die from TB in 2004

7. TB/HIV affects women with implications to their children

8. And it mostly affects the poor…

9. Interim policy on collaborative TB/HIV activities

10. Principles • “Two diseases, one patient”  Patient focused care delivery needed • There is an ongoing catastrophe  scale up of what has proved to work  Revision as more evidence evolves • No separate programme  Mainstreamed to existing strategies • Policy needs to be global  Countries need to adopt national policies

11. Policy Formulation Process • Under auspices of Global TB/HIV Working Group • Iterative drafting by writing committee: • technical experts from TB and HIV, • health management policy makers, • [one] person living with HIV / advocates, • international and national TB and HIV programme managers and donor agencies • Broad based consultation and review by both TB and HIV communities.

12. Goal To decrease the burden of TB and HIV in dually affected populations.

13. Objectives A. Establish the mechanisms for collaboration between TB and HIV/AIDS programmes. B. Decrease the burden of TB in PLWHA. C. Decrease the burden of HIV in TB patients.

14. Collaborative TB/HIV activities A. Establish the mechanism for collaboration A.1. TB/HIV coordinating bodies A.2. HIV surveillance among TB patient A.3. TB/HIV planning A.4. TB/HIV monitoring and evaluation B. To decrease the burden of TB in PLWHA B.1. Intensified TB case finding B.2. Isoniazid preventive therapy B.3. TB infection control in health care and congregate settings C. To decrease the burden of HIV in TB patients C.1. HIV testing and counselling C.2. HIV preventive methods C.3. Cotrimoxazole preventive therapy C.4. HIV/AIDS care and support C.5. Antiretroviral therapy to TB patients.

15. A.1. TB/HIV Joint Coordinating Bodies • Needed for effective TB and HIV programme efforts collaboration. • Should function at all levels overlooking the implementation of collaborative TB/HIV activities. • Important areas of responsibility for the Joint Coordinating Bodies (JCB) are: • Governance; resource mobilization for TB/HIV activities • Ensuring coherent joint communications, capacity-building, and training programs • Ensuring community participation in joint TB/HIV activities • Overseeing development of new evidence.

16. A.2. HIV surveillance among TB patients • All TB patients should be offered HIV testing. • Essential to inform programme planning and implementation. • Three surveillance methods can be used: • Periodic (special) • Sentinel • Routine Establish the mechanism for collaboration

17. A.3. Joint TB/HIV planning • Strategic planning to collaborate successfully and systematically. • Devise a joint TB/HIV plan or introduce parallel TB/HIV components in both the national TB control plan and national HIV/AIDS control plan. • Crucial elements include: • resource mobilization • capacity-building and training • TB/HIV communication (advocacy, programme communication and social mobilization) • enhanced community involvement • operational research.

18. A.4. Monitoring and Evaluation (M&E) • To assess quality, effectiveness, coverage, and delivery. • Involves collaboration among programmes and the general health system, and the development of referral linkages between different services and organizations. • Enables ongoing monitoring of collaborative activities scale-up and impact accessment.

19. B.1. Intensified TB case finding • Screening for TB symptoms and signs. • Advantages: • interrupts TB transmission by infectious cases • prevents mortality • decreases risk of nosocomial TB transmission • offers the opportunity to provide TB preventive therapy • improves TB case detection • Previously undiagnosed active TB detected in up to 11% of PLWHA in VCT centres; also detected in up to 50% of PLWHA in autopsy cases. Decrease the burden of TB in PLWHA

20. B.2.Isoniazid preventive therapy (IPT) • Given to individuals with latent TB infection (LTBI). • Prevents active TB disease in 40-60% of the patients. • Feasibility is difficult • identification of HIV-positive subjects • screening to exclude active TB • adherence to 6-9 months of isoniazid Decrease the burden of TB in PLWHA

21. Administrative level early diagnosis and treatment Separation of PTB suspect Environmental level maximise natural ventilation UV radiation Patient level protection of PLWHA IPT B.3.TB infection control in health care and congregate settings Decrease the burden of TB in PLWHA

22. Offers point for a continuum of TB and HIV/AIDS prevention, care, treatment, support services. The test readily available Voluntary confidentiality maintained All TB patients should be tested for HIV. C.1. HIV testing and counselling Decrease the burden of HIV in TB patients

23. C.2.HIV preventive methods • Sexual transmission • Condoms & education • STI treatment • Parenteral transmission • blood safety • Injection safety • Harm reduction • Vertical transmission • Antiretroviral drugs Decrease the burden of HIV in TB patients

24. C.3. Co-trimoxazole preventive therapy • Prevents secondary bacterial and parasitic infections • Reduces mortality among HIV-positive smear-positive tuberculosis patients • Reduces hospitalisation and morbidity among people living with HIV/AIDS • For HIV positive TB patients given throughout TB treatment (6/8 months) and beyond Decrease the burden of HIV in TB patients

25. Basic human right OI management prophylaxis early diagnosis rational treatment follow-up care Nursing care Palliative care Home care Counselling Social support. C.4.HIV/AIDS care and support Decrease the burden of HIV in TB patients

26. Improves quality and survival of life. Incentive to HIV testing Reduce incidence of TB by >80% Interaction of Rifampcin with certain ARVs In the absence of CD4 count all TB patients eligible 3 by 5 / Universal Access by 2010 C.6.Antiretroviral Therapy Decrease the burden of HIV in TB patients

27. Recommendations to start collaborative TB/HIV activities

28. Criteria Recommendation I National adult HIV prevalence rate 1% OR National HIV prevalence among tuberculosis patients is  5%. All activities in A, B and C A. Establish mechanism B. Decrease TB in PWA C. Decrease HIV in TB [All 12 activities] Areas with 1% adult HIV as in Category I [ 12 activities] Other parts of the country as in category III. [ 4 activities] National adult HIV prevalence rate below 1% AND Administrative areas with adult HIV prevalence rate 1% II National adult HIV prevalence rate below 1% AND No administrative areas with adult HIV prevalence rate  1% A.2. HIV surveillance among TB pts B.1.TB case finding in PLWHA B.2. IPT in PLWHA B.3. TB infection control III