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Strategic framework for TB/HIV Dermot Maher Stop TB Department World Health Organization

Strategic framework for TB/HIV Dermot Maher Stop TB Department World Health Organization Geneva, Switzerland On behalf of the Global TB/HIV Working Group IUATLD World Conference on Lung Health Montreal October 2002. Outline of presentation. Why a strategic framework to control TB/HIV?

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Strategic framework for TB/HIV Dermot Maher Stop TB Department World Health Organization

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  1. Strategic framework for TB/HIV Dermot Maher Stop TB Department World Health Organization Geneva, Switzerland On behalf of the Global TB/HIV Working Group IUATLD World Conference on Lung Health Montreal October 2002

  2. Outline of presentation • Why a strategic framework to control TB/HIV? • TB as part of the HIV/AIDS epidemic • Why joint TB and HIV/AIDS programme activities? • What interventions are available against TB/HIV? • Current status of implementation of interventions • A coherent health service response to TB/HIV • Essential package of HIV/AIDS care • From framework to implementation • What is needed for comprehensive action?

  3. The burden of HIV-related disease • At any stage High-grade pathogens, e.g. pneumococcus, non-typhoid salmonellae, Mycobacterium tuberculosis • More advanced immunosuppression Low-grade pathogens, e.g. candida, Cryptococcus neoformans, toxoplasma, Pneumocystis carinii, atypical mycobacteria

  4. How does HIV fuel the TB epidemic? 1. Promotes progression to TB of Mycobacterium tuberculosis infection - recently acquired - latent (most powerful known risk factor) In people co-infected with HIV and Mycobacterium tuberculosis, annual risk of TB = 5-15% 2. Increases rate of recurrent TB (endogenous/exogenous) 3. Increased TB cases in HIV-infected people pose risk of TB transmission to general community.

  5. TB/HIV overlapping epidemics The impact of HIV on the TB epidemic depends on the size of the overlap between the M tuberculosis infected and HIV infected populations Mycobacterium tuberculosis HIV overlap Region HIV epidemic TB/HIV epidemic TB/HIV HIV epidemic overlap Africa generalised +++ North America concentrated (IDU, MSM) + Western Europe North concentrated (MSM) – South concentrated (IDU) + Eastern Europe concentrated (IDU) + TB and HIV

  6. Dynamics of TB and HIV in Uganda 160 35 TB 140 30 HIV-national 120 25 HIV-Kampala 100 20 (%) HIV prevalence adults TB incidence/100,000 80 15 60 10 40 5 20 0 0 1975 1980 1985 1990 1995 2000

  7. A key fact At least 1 in 3 people with HIV will develop TB

  8. Implication for HIV/AIDS Programmes TB is a huge part of HIV/AIDS care

  9. Implication for TB Programmes Prevention of HIV is crucial to control TB

  10. Evolving international response to TB/HIV? Previously -“a dual strategy for a dual epidemic” (UNAIDS) TB and HIV/AIDS programmes have largely pursued separate courses Now - unified health sector strategy Controlling TB/HIV as an integral part of response to HIV/AIDS.

  11. Sequence of events in transmission of TB Transmission of infection M. tuberculosisinfection Recurrenceafter treatment Inadequatetreatment M.tuberculosisinfected person Untreated Active TB TB progression TB reactivation

  12. Sequence of events by which HIV fuels TB Transmission of infection M. tuberculosisinfection HIV infection Recurrenceafter treatment Inadequatetreatment M.tuberculosisinfected person Untreated Active TB TB progression TB reactivation

  13. Main biomedical interventions against M tuberculosis Transmission of infection M. tuberculosisinfection TB preventive treatment HIV infection Recurrenceafter treatment BCG Rifampicin containing regimens Inadequatetreatment M.tuberculosisinfected person  Intensified case-finding  Decreased diagnostic & treatment delays Untreated InterventionagainstM.tuberculosis Active TB TB progression Sequence of events: HIV-negative HIV-positive TB reactivation TB preventive treatment

  14. Main interventions to interrupt the sequence of events by which HIV fuels TB Transmission of infection M. tuberculosisinfection TB preventive treatment CondomsSTI treatment Safe IDU HIV infection Recurrenceafter treatment BCG Rifampicin containing regimens Inadequatetreatment M.tuberculosisinfected person  Intensified case-finding  Decreased diagnostic & treatment delays HAART Untreated InterventionagainstHIV InterventionagainstM.tuberculosis Active TB TB progression Sequence of events: HIV-negative HIV-positive TB reactivation TB preventive treatment

  15. Expanded scope of new strategy to control TB in high HIV prevalence populations Intensified TB case-finding and treatment Additional measures beyond TB case-finding and treatment • TB preventive therapy • Interventions to decrease morbidity and mortality in HIV-infected TB patients • Interventions to decrease HIV transmission • ARV therapy

  16. Status of implementation of interventions in sub-Saharan Africa in 2001 1) Condoms annual provision = 5 per man per year (17 in top 6 countries) 2 billion per year needed for all countries to match top 6 (Shelton JD, Johnston B. Br Med J 2001; 323: 139)

  17. 2) Antiretrovirals HIV-infected people treated with HAART = 30,000 (out of 30 million)

  18. 3) NTP performance in 24 countries with adult HIV seroprevalence > 5% Countries achieving WHO target successful treatment rate of 85% (corrected for high case fatality) Malawi Haiti (40%)

  19. A coherent health service response to TB/HIV (1) Strengthened TB programme activities Strengthened HIV/AIDS programme activities Joint TB and HIV/AIDS programme activities • planning • surveillance • training staff • drug supply and other logistics • case detection and management

  20. A coherent health service response to TB/HIV (2) Essential package of HIV/AIDS care in low-income countries Interventions including TB interventions at relevant levels of health care system: • home and community care • primary care • secondary care • tertiary care Criteria for prioritisation, e.g. cost-effectiveness TB treatment is one of the most cost-effective HIV/AIDS interventions (Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Creese et al. Lancet 2002; 359: 1635-42)

  21. From a strategic framework to national implementation strategies Stop TB Dept HIV/AIDS Dept UNAIDS national partners field experience (e.g. ProTEST Initiative) national implementation strategy strategic framework wide consultation and endorsement by Global TB/HIV Working Group who does what, when, with which funds, from where? the evidence for what is possible

  22. Needs in strengthening general health service providers • Increased funding for improved general health service provider capacity (human resources, infrastructure, commmodities) • Shift in policy: away from vertical HIV/AIDS services towards a strengthened response to meet the needs of high HIV prevalence populations • Operational research on TB and HIV programme collaboration in supporting health providers • Effective coordination of many role players

  23. Conclusion Increasing aid flows for priority diseases of poverty (AIDS, TB and malaria): • HIPC • GF ATM • Foundations, e.g. Gates commitment + $ + action -> results

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