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TB/HIV Update

TB/HIV Update. Central TB Division. Estimated HIV prevalence in new TB cases, 2008. National estimate – 4.85% of Incident TB cases are HIV positive. Proportion of Registered TB patients who are HIV+, 1q10. <1%. 1%-4.9%. 5%-9.9%. >10%. Highly Variable!!. Source: Central TB Division, 2009.

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TB/HIV Update

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  1. TB/HIV Update Central TB Division

  2. Estimated HIV prevalence in new TB cases, 2008

  3. National estimate – 4.85% of Incident TB cases are HIV positive

  4. Proportion of Registered TB patients who are HIV+, 1q10 <1% 1%-4.9% 5%-9.9% >10% Highly Variable!!

  5. Source: Central TB Division, 2009

  6. Treatment outcomes for HIV-positive and HIV-negative TB patients, 2006 cohort The numbers under the bars are the numbers of patients included in the cohort

  7. Treatment Outcomes of HIV positive and HIV negative TB patients, 4q08 (N=2034) (N=141304) (N=5422) (N=345661) All TB Patients NSP TB Patients

  8. After TB diagnosis, delayed ART initiation associated with higher death rates Lawn et al, CROI 2007

  9. SIGNIFICANT REDUCTION OF MORTALITY IN THE EARLY ARM ** per 100 person-years CAMELIA STUDY ANRS 1295/12160 - CIPRA KH001/10425 study

  10. EARLY ART INITIATION SIGNIFICANTLY REDUCES MORTALITY ** per 100 person-years Karim et al, Durban, SOUTH AFRICA

  11. “Nationally, RNTCP should be able to reverse the increases in TB burden due to HIV but, to ensure that TB mortality is reduced by 50% or more by 2015, HIV-infected TB patients should be provided with antiretroviral therapy in addition to the recommended treatmentfor TB.”

  12. Summary: TB-HIV Interaction in India India has the highest burden of TB, and a high burden of HIV in the world Most TB is among persons without HIV; magnitude variable HIV may slow down TB control efforts in India Particularly efforts to reduce mortality Enormous need for improved TB-HIV programme collaboration

  13. Response to TB-HIV

  14. TheSTOP TB Strategy, 2009 Updated language underlined • Pursue high-quality DOTS expansion and enhancement • Secure political commitment, with adequate and sustained financing • Ensure early case detection, and diagnosis through quality-assured bacteriology • Provide standardised treatment with supervision, and patient support • Ensure effective drug supply and management • Monitor and evaluate performance and impact • Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations • “Scale–up” collaborative TB/HIV activities • Scale-up prevention and management of multidrug-resistant TB (MDR-TB) • Address the needs of TB contacts, and poor and vulnerable populations • Contribute to health system strengthening based on primary health care • Help improve health policies, human resources development, financing, supplies, service delivery and information • Strengthen infection control in health services, other congregate settings and households • Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL) • Adapt approaches from other fields and sectors, and foster action on the social determinants of health • Engage all care providers • Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches • Promote use of the International Standards for Tuberculosis Care (ISTC) • Empower people with TB, and communities through partnership • Pursue advocacy, communication and social mobilization • Foster community participation in TB care, prevention and health promotion • Promote use of the Patients' Charter for Tuberculosis Care • Enable and promote research • Conduct programme-based operational research, and introduce new tools into practice • Advocate for and participate in research to develop new diagnostics, drugs and vaccines 2006/rev. 2009

  15. Evolution of TB-HIV collaborative activities in India 2001–First TBHIV “Joint Action Plan” developed; Basic activities in 6 high-HIV burden states 2003- Cross referral piloted in MH and initiated in 6 states 2004–Expanded to 8 additional States 2005–Joint training modules, surveillance 2007–Expanded surveillance, CPT/Routine referral pilot, National Framework for TB/HIV 2008–National Framework revised, all-India implementation begins with Intensified package in 9 states 2009 – National Framework revised, Intensified package scaled up to include 8 more states 2010 – Intensified package launched in 11 states

  16. Currently 11 states implementing (TN,AP,KA,MH,PD,GA,MZ,MN,NG,GU,DL) Launched in 7 states (AS,WB,OR,KE,RJ,PN,CH) IN 2009 Rolled out in 11 states in 2010 (HR,UK,HP,JH,CG,TR,ArP,ME,SI,MP,UP) Implementing Launched (2009) Launched (2010) Intensified TB-HIV package - Nationwide coverage by 2012

  17. National TB/HIV Framework 2009…1

  18. National TB/HIV Framework 2009…2

  19. All TBHIV Training Modules revised

  20. A new “TBHIV module for ART centre staff” created • Intensified TB case finding at ART centres with standardised R&R • Rifabutin use among HIV-infected TB patients receiving Second line ART or Alternative First line ART (containing Protease Inhibitors) approved • Infection control guidelines for ART centre setting included • ART in HIV-infected TB patients – regimen, timing of initiation, special situations clarified

  21. International & National Guidelines for ART in HIV-infected TB patients

  22. TB/HIV Performance

  23. Trends in Number (%) of registered TB patients with known HIV status, 4q08-1q10

  24. Proportion of TB patients with known HIV status, States, 1q10

  25. Proportion of TB patients with known HIV Status, 1q10 <49.9% 50%-79.9% >80%

  26. Proportion of Registered TB patients who are HIV+, 1q10 <1% 1%-4.9% 5%-9.9% >10%

  27. Number (%) of HIV+ TB patients receiving CPT during TB treatment, 4q08-2q09By quarter of TB registration

  28. Number (%) of HIV+ TB patients receiving ART during TB treatment, 4q08-2q09By quarter of TB registration

  29. Trends in Number of TB suspects referred from ICTC to RNTCP 2006–2009

  30. Trends in TB case detection from ICTC to RNTCP referrals, 2006–2009 (till September)

  31. Next Steps – 2010-15 • Intensified TB/HIV package - Nationwide coverage by 2012 • Provider-initiated HIV testing for all TB patients • Immediate and accountable linkage of HIV-infected TB patients to NACP for HIV care and treatment • Intensified TB case finding and reporting – Consolidation in all HIV care settings • Completed clinical and operational research on IPT for TB/HIV with policy decisions • Implementation of airborne infection control measures • HIV Surveillance among TB suspects at some sentinel sites • RCT among HIV-infected TB patients comparing daily v/s intermittent regimens

  32. Role of Medical College in TB/HIV collaborative activities • Academics • Frequent updates / CMEs for faculty and students • Demonstration of TB/HIV care settings to students • Patient Care • Implementation of ICF and IC at ICTCs and ART centres • Implementation of PITC for TB patients and Early ART initiation for HIV-infected TB patients • Research • Operational Research and PG Thesis • Funding available under RNTCP • Quality Assurance • Part of RNTCP Internal Evaluations and Joint TB/HIV Visits • Peer Pressure on professional colleagues to follow ISTC

  33. Thanks.. A dedicated webpage for TB-HIV

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