5 th dots expansion working group meeting, paris, october 28, 2004 tuberculosis and hiv - future...
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5 th DOTS Expansion Working Group Meeting, Paris, October 28, 2004 Tuberculosis and HIV - Future Directions . Paul Nunn, Stop TB Dept., WHO, Geneva. GLOBAL PARTNERSHIP TO STOP TB. Contents. Conclusion of 4 th DEWG Meeting, The Hague, 2003 - PowerPoint PPT PresentationTRANSCRIPT
5th DOTS Expansion Working Group Meeting, Paris, October 28, 2004
Tuberculosis and HIV - Future Directions
Paul Nunn, Stop TB Dept., WHO, Geneva GLOBAL
PARTNERSHIP TO STOP TB
Contents
• Conclusion of 4th DEWG Meeting, The Hague, 2003
• What DOTS Expanders can do for TB/HIV – and what TB/HIV can do for TB control
• 4th TB/HIV WG Meeting, Addis Ababa• Future directions• DISCUSSION
4th DEWG: Rationale for Joint TB/HIV Activities
• HIV drives TB incidence and mortality in high HIV prevalence areas
Estimated TB incidence vs HIV prevalence
0
200
400
600
800
0.0 0.1 0.2 0.3 0.4HIV prevalence, adults 15-49 years
Estim
ated
TB
inci
denc
e (p
er 1
00K
, 199
9)
4th DEWG: Rationale for Joint TB/HIV Activities
• HIV drives TB incidence and mortality in high HIV prevalence areas
• TB significant cause of mortality among HIV/AIDS patients
• Where HIV is high and rising, DOTS alone is insufficient to control TB
• Principles of equity demand greater efforts
Regional TB incidences
0
50
100
150
200
250
1980 1985 1990 1995 2000
Cas
e no
tific
tions
/100
,000
pop
rest of world
SSA
FSU
Epidemic in sub-Saharan Africa Epidemic in sub-Saharan Africa 19851985−−2003 2003
0
5
10
15
20
25
30
1985198619871988198919901991199219931994199519961997199819992000200120022003
Milli
ons
0
5
10
15
20
25
30
% HIVprevalence adult (15-49)
Number of people living with HIV and AIDS% HIV prevalence, adult (15-49)
Year
Source: UNAIDS/WHO, 2004
2004 Report on the Global AIDS Epidemic (Fig 5)
4th DEWG: Rationale for Joint TB/HIV Activities• HIV drives TB incidence and mortality in high HIV
prevalence areas• TB significant cause of mortality among HIV/AIDS
patients• Where HIV is high and rising, DOTS alone is insufficient
to control TB• Principles of equity demand greater efforts • Joint TB/HIV interventions are needed to control HIV-
associated TB– With up to 70% TB patients HIV infected, concomitant patient
access to both HIV and TB services essential• TB control system can be a major partner for ARV
delivery and thus for 3 by 5, PEPFAR etc• TB/HIV policy endorsed by DEWG
New imperatives
• Standard of care• Human rights based approach• Patient-centred care • MDG targets include prevalence and
mortality
TB/HIV Collaborative ActivitiesEstablish mechanisms for collaboration• Set up a coordinating body for TB/HIV activities • Conduct surveillance of HIV prevalence among tuberculosis patients• Carry out joint TB/HIV planning• Conduct monitoring and evaluation Decrease the burden of tuberculosis in people living with HIV/AIDS• Establish intensified tuberculosis case-finding• Introduce isoniazid preventive therapy• Ensure tuberculosis infection control in health care and congregate settingsDecrease the burden of HIV in tuberculosis patients• Provide HIV testing and counselling• Introduce HIV prevention methods• (Introduce co-trimoxazole preventive therapy)• Ensure HIV/AIDS care and support• Introduce antiretroviral therapy
Establish mechanisms for collaboration
New policy:• Set up a coordinating
body for TB/HIV activities
• Conduct surveillance of HIV prevalence among tuberculosis patients
• Carry out joint TB/HIV planning
• Conduct monitoring and evaluation
Advantages for TB control:• Creates a mechanism
for cooperation• Measures the size of
the TB/HIV problem• Creates a route towards
patient-centred care• Enables understanding
of extent you are succeeding and the impact you are having
Decrease the burden of tuberculosis in people living with HIV/AIDS
New policy:• Establish intensified
tuberculosis case-finding
• Introduce isoniazid preventive therapy
• Ensure tuberculosis infection control in health care and congregate settings
Advantages for TB control:• Increases case
detection• Prevents TB cases from
occurring – lowers case load
• Prevents transmission in places you are responsible for (primum non nocere)
Decrease the burden of HIV in tuberculosis patients
New policy:• Provide HIV testing and
counselling• Introduce HIV
prevention methods• (Introduce co-
trimoxazole preventive therapy)
• Ensure HIV/AIDS care and support
• Introduce antiretroviral therapy
Advantages for TB control:• Identifies those in need
of HIV care (co-trimoxazole; ARVs; avoid thiacetazone; psycho-social care etc)
• Limits HIV spread (and hence TB)
• Reduces morbidity and mortality (MDG targets) and improves TB treatment outcome
• TB control system can be a major partner for ARV delivery scale up and therefore for achieving the goals of– PEPFAR– GFATM– World Bank– UNAIDS – The Millennium Development project– The "3 by 5" Initiative
4th TB/HIV WG Meeting Theme: "Two diseases- one patient: scaling up prevention and treatment for TB and HIV"
• Minimum essential set of guidelines prepared• Countries moving• Monitoring and evaluation system in place and
baseline for 2002/2003• Training cascade underway• HIV/TB Task Force in WHO• Strong partnership• Advocacy environment
transformed
Mandela urges action to fight TBBy Chris Hogg BBC Bangkok
Mandela sounds alarm on TB "death sentence" in AIDS war By Darren Schuettler
BANGKOK (Reuters) – The global war on AIDS could be lost if the world ignores tuberculosis, often a "death sentence" for people infected with HIV, former South African president Nelson Mandela said on Thursday.
BANGKOK: by Lawrence K. Altman –
Nelson Mandela came to the 15th International AIDS Conference here Thursday to lend his prestige to the battles against tuberculosis and AIDS, two deadly diseases that are intricately linked.
Conclusions – 4th WG Meeting, Addis
• Significant progress since Montreux• Movement good - long way to go• HIV activist community engaging• Partnership expanding• Support for joint TB/HIV activities from
– African Union, Ethiopian PM, Director CDC• Focus now implementation in countries• Strengthen systems to measure
progress
"…all member states should embrace and scale up implementation of collaborative TB/HIV activities."
African Union, Addis Ababa, September 2003
Conclusions and recommendations4th WG Meeting, Addis - II• WG should add its voice to
– Concerns about funding flows– Insufficient human resources– Inadequate political commitment– Insufferable debt burden
• TB is too technical, too public health oriented– Patient centred care needed– HIV testing is gateway to HIV services– Better care for smear negatives, EPTB, especially more
rapid diagnosis• New tools needed• Need to explore harm reduction for IDUs with TB• Research priorities should be determined
"Our work should be measured by how many people we put on antiretroviral therapy through our TB programs and by how many people we put on anti-TB and IPT through our HIV/AIDS programs in each country".
Zackie Achmat, Treatment Action Campaign, Addis Ababa, September 2003
Future directions – and needs• Country implementation
– Technical assistance– Expand evidence base– R5 GFATM– Measure progress (surveillance, M&E)
• Advocacy at country level– Support alliance with advocates
• Increase partnership activity– Regional and partners' take-up of TB/HIV
• New tools– Coordination with countries
• Funding– Sustainable
Issues for discussion
• How will TB community increase country level implementation?– HIV testing for TB patients– Better diagnosis for smear negative
patients– Advocating for standard of care– Psychosocial care– Harm reduction for IDUs