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From Mekong to Bali: Scale up of HIV/TB Collaborative Activities in Asia Pacific. Key Outcomes What next for Asia?

From Mekong to Bali: Scale up of HIV/TB Collaborative Activities in Asia Pacific. Key Outcomes What next for Asia?. Massimo N Ghidinelli HSI WPRO The 15 th Core Group Meeting of the TB/HIV Working Group 3-4 November 2009, Chateau de Penthes - Geneva. Outline.

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From Mekong to Bali: Scale up of HIV/TB Collaborative Activities in Asia Pacific. Key Outcomes What next for Asia?

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  1. From Mekong to Bali: Scale up of HIV/TB Collaborative Activitiesin Asia Pacific. Key Outcomes What next for Asia? Massimo N Ghidinelli HSI WPRO The 15th Core Group Meeting of the TB/HIV Working Group 3-4 November 2009, Chateau de Penthes - Geneva

  2. Outline • From Mekong (2004) to Bali (2009). Context, objectives, and highlights of TB/HIV regional consultations • Progress in implementing collaborative activities • Observations and Conclusions

  3. From Mekong to Bali: The Scale up of TB/HIV Collaborative Activities in Asia Pacific Region 8-9 August 2009, Bali 127 persons from 18 countries from Asia-Pacific

  4. Objectives/Sessions • Review progress and lessons learned since 2004 Greater Mekong meeting. Update on regional policy and strategies, review of successful collaborative TB/HIV activities • Review successes and challenges and measures to enhance collaboration between TB and HIV programmes, partners, NGOs, businesses, and communities • Provide updates on global policies related to TB/HIV management, monitoring and evaluation and to examine developments in local operational research and TB in migrants • Breakout session to discuss best practices, identify constraints, and possible solutions to expand TB/HIV scale-up to inform action points for national operational plans on TB/HIV • Develop a framework for country specific priorities to accelerate the implementation of TB/HIV activities • Develop and strengthen partnerships and increase funding for TB/HIV activities

  5. HIV/AIDS in the Asia Pacific Region • Second highest HIV burden in the world • Estimated 4.9 million people living with HIV/AIDS • >95% burden borne by 9 low and middle-income countries High HIV Burden Countries in Asia Pacific Cambodia, China, India, Indonesia, Myanmar, Nepal, Papua New Guinea, Thailand, Vietnam

  6. HIV prevalence in new TB cases (2007) HBC Source: TB Control in the WPR 2009 Report

  7. Estimated morbidity and mortality due to TB/HIV co-infection in the Western Pacific Source: Global Tuberculosis Control 2009, WHO, Geneva

  8. HIV seroprevalence among TB cases Source: Tuberculosis Control in the South-East Asia Region, WHO/SEARO, New Delhi, March 2009

  9. ART Scale-up in the Asia Pacific Region: 2003-2008

  10. ART Services in the Asia Pacific Region, 2008

  11. Mekong Meeting 2004Rationale • HIV fuels TB epidemic & threatens TB control • Limited data on HIV/TB co-infection and low awareness • Lack of collaboration between NTP and NAP • ART scale up (3by5) and role of NTP

  12. Outcome of Mekong Conference • 127 participants from 11 countries, 5 day meeting • Experiences, lessons learned shared: 6 focus countries + partner organizations • WHO WPRO TB/HIV framework discussed • Country action plans developed & presented (Cambodia, China, Laos, Myanmar, Thailand, Viet Nam)  pilot phase

  13. First Regional TB-HIV Framework 2004

  14. A revised framework in 2008 to address TB-HIV co-infection in the Western Pacific Region

  15. WHO Policy on TB/HIV Strategy for TB-HIV in the SEA Region + the “4th I” “Integrated case management” 3 I’s • + D. Systems strengthening • Establish regular interaction • Resource mobilization • Capacity building • Involve communities, NGOs

  16. Policies and Services on TB/HIV in 2008 Source: Universal Access Progress Report 2007 and 2008.WHO, UNAUIDS, UNICEF

  17. HIV/TB collaborative activities 2007-2008 in WPR countries Source: Universal Access Progress Reports 2007 and 2008. WHO, UNAIDS, UNICEF

  18. Reported TB/HIV data (2007) Source: Global TB Control 2009, WHO Geneva

  19. Intensified Case Finding – Screening for TB at ICTCs India, 2005-2008 > 8 fold increase in referrals Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies

  20. TB Cases Detected through ICF: India 2005–2008 > 7 fold increase Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies

  21. Intensified TB finding among newly detected PLHIV in Thailand, 2006-8 % newly detected PHAs Source: Bureau of Tuberculosis Control, Dept of Disease Control, MopH Thailand, July 2009

  22. TB patients Newly HIV Tested: India2005-2008 > 4 fold increase Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies

  23. IPT Not policy in any country Being piloted in Myanmar and Thailand Commonly heard concerns: • It is difficult to rule out active TB; so we may end up giving monotherapy • INH resistance is high; IPT could further magnify INH resistance. • Managing adherence to IPT is too complicated and would be costly • Not so effective—and IPT efficacy wanes with time

  24. MekongBali-Observations Dramatic shift in perceptions on TB/HIV • HIV programmes in Asia • begin to implement TB ICF • explore IPT as an extension of ICF for those who are well • recognize IC in HIV care settings requires urgent action • build TB into funding proposals, routine activities, M&E • TB programmes in Asia • view TB/HIV as core activity • include HIV data in routine recording/reporting • find and refer co-infected patients to HIV care & ART • Both programmes • committed to working together to mitigate dual burden of TB/HIV, and strengthen health systems along the way

  25. Bali-Highlights and Conclusions • Good progress since Mekong Conference. High level uptake of PITC, ICF varied, low IPT and IC, 4th I promising • Collaboration between NAP and NTP improving, though still insufficient in many countries. Structural corrections? • Multi-sectoral developments needed (private sector, Min. of Labour, Unions, Civil society, NGO’s, Faith based organizations)

  26. Bali-Conclusions 2 • Communities involvement and participation: great potential PLHA rights based approach, balance heavy medical approach of TB • Encouraging examples of extension of TB services into Harm Reduction services for IDU. Issues of stigma • Strengthen monitoring functions  better and more reliable data needed by programmes, to sustain advocacy and document achievements. • Document good experiences through case studies

  27. Bali-Conclusions 3 • Engage/include TB services into “linked responses” (HIV/STI/RSH services) • Concerns about women’s vulnerability and social exclusion. Include TB services for HIV+ mothers through PMTCT • Slow progress of IC efforts. Risk of fragmentation, but opportunity to integrate IC into HSS and submit proposals for funding

  28. Bali-Conclusions last • Urgent need to improve communication, especially in support of ICF (TB Diagnostic algorithm), and IPT addressing decision makers, professional bodies-experts, and beneficiaries • Investment on operational research, in developing better tools for ICF (diagnostic algorithm) and IPT (cost effectiveness and benefit analysis) • Momentum for funding, especially for TB

  29. Acknowledgments • HIV and TB Programmes in Asia Pacific Countries • Nani Nair, StopTB SEARO • Padmini Srikantiah, HIV SEARO • Puneet Dewan, StopTB SEARO • Pieter van Maaren, StopTB WPRO • Katsunori Osuga, StopTB WPRO • Fabio Mesquita, HSI WPRO • Teodi Wi, HIS WPRO • Nguyen Thuy, HSI WPRO • Yu Dongbao, HSI WPRO

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