from mekong to bali: scale up of hiv/tb collaborative ... · • review progress and lessons...
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World Health
Organization
Western Pacific Region
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 15th Core Group Meeting of the TB/HIV Working Group
3-4 November 2009, Chateau de Penthes - Geneva
World Health
Organization
Western Pacific Region
Outline
• From Mekong (2004) to Bali (2009). Context, objectives, and highlights of TB/HIV regional consultations
• Progress in implementing collaborative activities
• Observations and Conclusions
World Health
Organization
Western Pacific Region
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
World Health
Organization
Western Pacific Region
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
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
World Health
Organization
Western Pacific Region
HIV prevalence in new TB cases (2007)
0
4
8
12
16
20
Mon
golia
Phili
ppin
es
Japa
n
Rep
ublic
of K
orea
New
Zea
land
Chi
na Fiji
Aus
tralia
Lao
Peo
ple'
s D
emoc
ratic
Rep
ublic Si
ngap
ore
Cam
bodi
a
Vie
t Nam
Mal
aysi
a
Papu
a N
ew G
uine
a
HIV
pre
vale
nce
(%
)
HBC
Source: TB Control in the WPR 2009 Report
World Health
Organization
Western Pacific Region
Estimated morbidity and mortality due to TB/HIV co-infection in the Western Pacific
Estimated TB/HIV burden in the Western Pacific
(selected countries)
51,483
24,705
12,052
5,560
4,433
2,930
874
295
14,503
6,774
3,101
1,843
1,296
1,049
271
99
0 10,000 20,000 30,000 40,000 50,000
WPR Total
China
Viet Nam
Cambodia
Malaysia
Papua New Guinea
Philippines
Lao PDR
Number
Number of TB/HIV deaths
Number of TB/HIV cases
Source: Global Tuberculosis Control 2009, WHO, Geneva
HIV seroprevalence among TB cases
Country Estimated HIV
seroprevalence
among incident TB
cases
Country Estimated HIV
seroprevalence
among incident
TB cases
Bangladesh < 0.05 % Myanmar 10.9%
Bhutan Not available Nepal 2.4%
DPR Korea Not applicable Sri Lanka 0.2%
India ~4- 5% Thailand 13-24%
Indonesia 2% -15% (Papua) Timor-Leste <100 cases of
HIV reported/yr
Maldives <5 cases of HIV
reported/yr
Source: Tuberculosis Control in the South-East Asia Region, WHO/SEARO, New Delhi, March 2009
ART Scale-up in the Asia Pacific Region:
2003-2008
0
100,000
200,000
300,000
400,000
500,000
600,000
2003 2004 2005 2006 2007 2008
Year
Nu
mb
er
of
Pers
on
s R
eceiv
ing
AR
T
ART Services in the Asia Pacific Region, 2008
Country Number HIV-Infected
(% Adult Prevalence)
Year ART
Program Started
Currently Receiving ART
Cambodia 61,400 (0.90%) 2001 31,999
China 700,000 (0.05%) 2002 48,254
India 2,300,000 (0.36%) 2004 199,237
Indonesia 270,000 (0.20%) 2005 10,616
Myanmar 240,000 (0.67%) 2005 15,191
Nepal 70,000 (0.42%) 2004 2,536
PNG 60,000 (1.6%) 2004 5,195
Thailand 530,000 (1.4%) 2000 166,747
Vietnam 280,000 (0.53%) 2005 27,059
World Health
Organization
Western Pacific Region
Mekong Meeting 2004 Rationale
• 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
World Health
Organization
Western Pacific Region
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
World Health
Organization
Western Pacific Region
First Regional TB-HIV
Framework 2004
World Health
Organization
Western Pacific Region
World Health
Organization
Western Pacific Region
A revised framework in 2008 to address
TB-HIV co-infection in the Western Pacific Region
WHO Policy on TB/HIV
+ the “4th I”
“Integrated case
management”
+ D. Systems strengthening
• Establish regular interaction
• Resource mobilization
• Capacity building
• Involve communities, NGOs
Strategy for TB-
HIV in the SEA
Region
3 I’s
World Health
Organization
Western Pacific Region
Policies and Services on TB/HIV in 2008
Country Services available to
screen TB for
PLHA
IPT for
PLHA
(policy-
guidelines)
IPT as part
of HIV care
Infection control
policy for TB in
health facilities
Brunei Darussalam no no no yes
Cambodia yes no no yes
China yes no yes
Fiji yes no no
Lao PDR yes no no yes
Malaysia yes no no yes
Mongolia yes no no yes
Papua New Guinea yes yes yes yes
Philippines yes no yes yes
Singapore yes
Viet Nam yes no no yes
Source: Universal Access Progress Report 2007 and 2008.WHO, UNAUIDS, UNICEF
World Health
Organization
Western Pacific Region
HIV/TB collaborative activities 2007-2008 in WPR countries
Country
No. (%) HIV+ incident TB cases
that received treatment for TB
and HIV
No. (%) newly-enrolled in HIV
care given isoniazid preventive
therapy (IPT)
No. (%) of those enrolled in
HIV care who had TB status
assessed and recorded during
their last visit
2007 2008 2007 2008 2007 2008
Cambodia NA NA NA NA NA (85.7 in 1 site)
China NA NA NA NA NA NA
Fiji 1 NA 0 2 (100) 9 11 (14)
Laos 453 293 NA NA 131 (71.6) NA
Malaysia 72 (33.5) 30 NA NA 2002 (89.3) 1958 (88.0)
Mongolia NA 0 0 0 (0) 4 (12.5) 10 (26.0)
Philippines 9 (49.3) 129 (46.0) NA NA NA NA
PNG 320 555 (8.0) 215 (29.8) 47 (2) 870 (38.7) 1487 (67.0)
Viet Nam NA NA NA NA NA NA
Source: Universal Access Progress Reports 2007 and 2008. WHO, UNAIDS, UNICEF
World Health
Organization
Western Pacific Region
Reported TB/HIV data (2007)
Source: Global TB Control 2009, WHO Geneva
All notified TB cases
# of TB cases tested for
HIV
Of which tested +ve for HIV
Of HIV +ve, # of cases on CPT
Of HIV +ve, # of cases
on ARV
China 1,045,939 34,557 (3.3%) 1,187 (3.4%) 679 519
Vietnam 98,344 14,377 (15%) 627 (4.4%) NA NA
Cambodia 36,495 14,245 (39%) 2,922 (21%) 1,101 610
Malaysia 16,918 10,082 (60%) 1,629 (16%) NA NA
Lao PDR 4,010 424 (11%) 155 (37%) 149 75
Intensified Case Finding – Screening for
TB at ICTCs India, 2005-2008
23
95
0 60
51
2
13
21
46
18
95
30
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
2005 2006 2007 2008
Nu
mb
er
HIV positive HIV negative Total
> 8 fold increase in referrals
Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies
0
5,000
10,000
15,000
20,000
25,000
30,000
2005 2006 2007 2008
Nu
mb
er
of
TB
cases a
mo
ng
IC
TC
refe
rrals
> 7 fold increase
Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies
TB Cases Detected through ICF: India
2005–2008
% n
ew
ly d
ete
cte
d P
HA
s
Intensified TB finding among newly detected
PLHIV in Thailand, 2006-8
8189
93
812 14
0
10
20
30
40
50
60
70
80
90
100
2549 (2006) 2550 (2007) 2551 (2008)
Target ≥ 90
TB screening
Known HIV positive TB
Patients
Source: Bureau of Tuberculosis Control, Dept of Disease Control, MopH Thailand, July 2009
TB patients Newly HIV Tested: India
2005-2008
29488
59654
91807
125756
11870
(9%)
10426
(11%)8785
(15%)6411
(21%)
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
2005 2006 2007 2008 (upto Oct)
Nu
mb
er
No.of TB pts HIV tested No. detected HIV infected
> 4 fold increase
Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies
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
World Health
Organization
Western Pacific Region
MekongBali-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
World Health
Organization
Western Pacific Region
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)
World Health
Organization
Western Pacific Region
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
World Health
Organization
Western Pacific Region
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
World Health
Organization
Western Pacific Region
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
World Health
Organization
Western Pacific Region
• 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
Acknowledgments