tb-hiv in the south-east asia region 13 th core group meeting of the tb/hiv working group april...
TRANSCRIPT
-
TB-HIV in the South-East Asia Region
13th Core Group Meeting of the TB/HIV Working GroupApril 17-18 New York, USA
Dr Nani Nair Regional Advisor-TB
-
TB and HIV in South-East AsiaOutlineEpidemiology of TB and HIVContext, issues and concernsThe ResponseFuture steps
-
But most of worlds TB cases are in the SEA RegionThe Burden:
5 million TB cases 3 million new cases/ year 500 000 TB deaths/ year 4 million people with HIV/AIDS Multi-drug resistance: 2.8% among new cases 18.8% among previously treated casesSource: Tuberculosis in the South-East Asia Region, WHO/SEARO, March 2008
Chart3
1154428
175100
240146
163167
1602810
1097378
2004
Sheet1
Fig 1
251908
BAN
BHU
KRD
IND
INO
MAV
MMR
NEP
SRL
THA
TLS
Sheet1
0.05200.0520
0.0770.70.0770.7
0.130.13
0.170.17
0.260.26
0.350.35
0.450.45
0.57410.5741
0.64213122980.6421312298
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Fig. 1: Progress in population coverage andDOTS case detectionSEA Region, 1997-2005
Sheet2
1154428
175100
240146
163167
1602810
1097378
2004
Sheet3
9925
10226
8925
8626
9632
9233
9036
9438
9642
10649
10851
All TB cases (rate)
New ss+ (rate)
Fig. 3: TB notifications (all cases and new smear-positive cases)SEA Region, 1995-2005
0.010.11
0.040.16
0.050.18
0.080.21
0.130.24
0.180.28
0.270.32
0.350.37
0.440.45
0.570.53
0.642005
SEAR
Global
Fig. 4: Case-detection ratesSEA Region, 1995-2005
1304828
254601
107997
123118
51266
50474
51696
2005
Fig.5: Distribution of all notified TB casesSouth-East Asia Region, 2005
86.811637122659.8271072189
149.756478417745.804364799
189.718961223879.1355389541
104.667151846545.9366795031
114.283085182371.2089451075
37.082066869320.0607902736
211.819315505172.331202122
123.274241698353.8716691851
44.656028539723.33799354
79.812557408241.1579717591
397.7824709609109.2925026399
107.618770240951.4780193094
398
All cases
New ss+
cases per 100 000 population
Fig. 6: Notification Rate, New Smear-Positive CasesSEA Region, 2005
0.2554748902
0.2535902967
0.2823440524
0.2987949565
0.3287086359
0.3606582531
0.3973712664
0.4084717167
0.4333808872
0.4841397368
0.5061169292
Positivity rate
Fig. 7: Evolution of smear-positivity rate
63853
75696
19670
93622
240640
585185
851981
DOTS
Fig. 8: Notified cases by treatment categoriesSEA Region, 2005
0.5873201544
1.3189365059
1.5743244127
2.2669172233
2.8466053088
3.056448939
3.6247899496
m:f ratio
age group
Fig 9: M:F ratio among new smear-positive cases per age groupSEA Region, 2005 notifications
50218549
9445371613
12030276415
12184053747
10670537485
7374624128
4529912497
male
female
Age group
Number of cases
Fig. 10: Distribution of cases per age and sex groupNew ss+ cases, SEA Region, 2005
0.6580.062
0.660.06
0.680.06
0.770.06
0.80.05
0.810.05
0.820.03
0.830.04
0.5870.077
0.610.11
0.560.14
0.570.14
0.650.04
0.680.04
0.660.05
0.520.22
New cases
Retreatment cases
cured
completed
Figure 11: Treatment success ratesSEA Region, 1997-2004 cohorts
0.88474176160.01175551090.03828117520.0070022650.02783360450.0303856828
0.7840.05066666670.04533333330.00266666670.01866666670.0986666667
0.83516424050.05287082630.02115915360.03365983010.0292764760.0278694735
0.83870011470.02272307410.04417015020.0239539610.06640559550.0040471045
0.81324381110.08206635090.02539133670.01145905210.05043378480.0174056644
0.954545454500.0303030303000.0151515152
0.75284661750.08295856860.05501865850.02216693780.06209932060.024909897
0.85951827020.01519091280.05309976730.0175174490.02894484740.0257287533
0.83579429740.01654786150.0493890020.00585539710.08223014260.0101832994
0.64906231310.03444636010.07508532420.01498891660.05587417750.1705429084
0.6650.1330.0470.0060.0910.058
0.82753111150.03560361070.04172860720.0199846710.05835492150.0167970782
cured
completed
died
failure
defaulted
not evaluated
Fig. 12: Treatment outcome in new ss+ casesSEA Region, 2004 cohort
0.76051103370.05133565620.04018583040.02810685250.05946573750.0603948897
0.71111111110.11111111110.02222222220.088888888900.0666666667
0.63166345540.1220295440.0463498180.12331406550.03992721040.0367159067
0.49893760870.23181480840.0685166170.04472210080.14827221620.0077366489
0.62068186950.19575524950.04425378190.0322871980.06638067280.0406412283
0.800.2000
0.59304221780.14151114330.08751585430.05888747960.07646312740.0425801776
0.79914529910.01673789170.06445868950.04522792020.07086894590.0035612536
0.6448362720.0403022670.07052896730.02267002520.19899244330.0226700252
0.61027503890.05604566680.1312921640.06694343540.07317073170.0622729632
0.83333333330.04761904760.071428571400.04761904760
0.51917799110.21632490190.06752976120.04791948390.1371566650.0118911969
cured
completed
died
failure
defaulted
not evaluated
Fig. 13: Treatment outcome in retreatment ss+ casesSEA Region, 2004 cohort
0.7720.50.85
0.7210.85
0.72
0.73
0.83
0.8
0.85
0.8631347221
0.8631347221
1997
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Fig. 14: Trends in case-detection and treatment success ratesSEA Region, 1997-2005
0.190
0.240.7
0.25
0.24
0.26
0.32
0.33
0.39
0.59
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection
0.720.50.85
0.7810.85
0.8
0.81
0.82
0.84
0.84
0.85
0.9
1997
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
0
0.240.7
0.27
0.26
0.31
0.32
0.33
0.317573595
0.9535603715
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection
0.50.85
0.2410.85
0.9
0.85
0.9
0.94
0.86
0.8984375
0.8346666667
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment results
0
0.7
0.02
0.26
0.53
0.79
0.91
1.02
0.9938013068
1997
1997
1997
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection
0.50.85
10.85
0.02
0.95
0.91
0.91
0.88
0.884
0.8880350668
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
0.010
0.0150.7
0.064
0.12
0.24
0.31
0.47
0.58
0.622232589
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection
0.790.50.85
0.81810.85
0.84
0.82
0.84
0.85
0.87
0.862
0.8614231888
1997
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
0.0740
0.120.7
0.19
0.19
0.2
0.27
0.33
0.54
0.6546850174
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection
0.8130.40.85
0.54510.85
0.58
0.5
0.87
0.86
0.86
0.867
0.895310162
1997
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
0
0.240.7
0.27
0.26
0.31
0.32
0.33
0.317573595
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
population coverage
DOTS detection rate
0.50.85
0.2410.85
0.9
0.85
0.9
0.94
0.86
0.8984375
1997
1998
1999
2000
2001
2002
2003
2004
DOTS detection rate
Treatment success rate
0.90
0.820.7
1.06
0.81
0.79
0.87
1.06
1.05
0.9295774648
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection
0.9340.40.85
0.94710.85
0.94
0.94
0.97
0.97
0.95
0.91
0.9545454545
1997
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
0.250
0.280.7
0.33
0.48
0.56
0.65
0.73
0.84
0.9603416557
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection rate
0.7910.50.85
0.81810.85
0.83
0.81
0.82
0.81
0.81
0.806
0.8358051861
1997
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
0.110
0.160.7
0.44
0.56
0.56
0.57
0.6
0.6955
0.6684196086
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection rate
0.8470.50.85
0.86810.85
0.89
0.87
0.86
0.88
0.86
0.87
0.874709183
1997
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
0.710
0.750.7
0.76
0.68
0.73
0.71
0.7
0.76
0.8649276398
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection
0.7990.50.85
0.76510.85
0.76
0.84
0.77
0.8
0.81
0.808
0.8523421589
1997
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
0.0050
0.210.7
0.4
0.46
0.73
0.65
0.72
0.72
0.6568361947
1997
1997
1997
1997
1998
1999
2000
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection
0.7780.50.85
0.62210.85
0.67
0.77
0.69
0.75
0.74
0.727
0.6835086732
1997
1998
1999
2000
2001
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
0
0.7
0.59
0.53
0.43
0.467268623
1997
1997
1997
2001
2002
2003
2004
2005
population coverage
DOTS detection rate
Progress in population coverage andDOTS case detection
0.50.85
10.85
0.73
0.81
0.806
0.798
2002
2003
2004
2005
DOTS detection rate
Treatment success rate
Progress in DOTS case detection andtreatment success
524751
81706776
104436785
114235538
110383960
84762281
75531230
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
19
4745
5838
2613
2311
149
122
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
4617
5023
4926
5529
5928
5528
5429
5733
6037
7145
8760
&A
Page &P
All TB cases
New smear-positive cases
cases per 100 000 pop.
TB notification rates, 1995-2005
7220
6917
6415
6614
5916
5517
4917
5017
4516
4416
15046
All TB cases
New smear-positive cases
cases per 100 000 pop.
TB notification rates, 1995-2005
84848
23076
11318
3876
0
1092
0
Bangladesh
2005 Case notification by type of patientTotal notified: 124 210
308
272
387
40
7
4
0
`
Bhutan
2005 Case notification by type of patientTotal notified: 1018
0.8847417616
0.0117555109
0.0382811752
0.007002265
0.0278336045
0.0303856828
Bangladesh
Treatment resultsNew ss+, 2004 cohort (n = 62 694)
167166
14091127
24221758
26881890
20401381
1185764
48533
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
31476257
6243444955
7444445458
7670228443
6465716938
4294610466
246355370
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
846946
1521513916
2090616393
1840113022
1784710927
135097539
63902783
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
01
910
87
51
62
62
54
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
132147
34012376
58773047
58882563
45852101
25571218
1764885
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
148195
19461208
16851111
1722797
1806658
1759532
820230
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
919
341295
520261
724189
918200
657154
424130
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
3950
1345778
37901467
41451215
36661247
25851145
31641801
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
88
136127
14990
11676
11960
5218
4729
male
female
Age group (years)
Notification per age groupnew smear-positive cases, 2005
5118
52
5623
15374
13164
17882
18477
19782
19079
All TB cases
New smear-positive cases
cases per 100 000 pop.
TB notification rates, 1997-2005
13128
13631
11728
11228
12235
11034
10537
10138
10141
10746
10546
All TB cases
New smear-positive cases
cases per 100 000 pop.
TB notification rates, 1995-2004
1816
126
1110
2016
3324
4025
4325
7135
8142
9960
11471
All TB cases
New smear-positive cases
cases / 100 000 pop.
TB notification rates, 1995-2005
9246
8241
6536
6432
5431
4522
4620
4019
4321
4721
3720
All TB cases
New smear-positive cases
Cases per 100 000 pop.
TB notification rates, 1995-2005
4120
5022
3821
3222
4224
6536
8944
11749
15355
19563
21272
All TB cases
New smear-positive cases
cases per 100 000 pop.
TB notification rates, 1995-2005
9541
10748
11052
10750
11958
12658
12357
12356
12357
12758
12354
All TB cases
New smear-positive cases
cases per 100 000 pop.
TB notification rates, 1995-2005
7935
6829
5122
2713
4925
5629
8146
8041
8745
8845
8041
All TB cases
New smear-positive cases
cases per 100 000 pop.
TB notification rates, 1995-2005
374148
355132
409129
398109
All TB cases
New smear-positive cases
cases per 100 000 pop.
TB notification rates, 2002-2005
17796
18123
5381
1364
1524
1018
5210
DPR Korea
2005 case notification by type of patientTotal notified: 50 416
506852
392390
170948
75028
17764
72089
58642
India
2005 case notification by type of patientTotal notified: 1 293 713
158640
85373
6142
4446
0
0
0
Indonesia
2005 Case notification by type of patientTotal notified: 254 601
66
23
29
4
0
0
1
Maldives
2005 Case notification by type of patientTotal notified: 123
36541
35601
30252
4615
0
982
0
Myanmar
2005 case notification by type of patientTotal notified: 107 991
14617
9474
7013
2344
316
313
0
Nepal
2005 case notification by type of patientTotal notified: 34 077
4841
2191
1913
263
55
186
0
Sri Lanka
2005 case notification by type of patientTotal notified: 9449
26437
16520
6703
1606
0
0
0
Thailand
2005 case notification by type of patientTotal notified: 51 266
1035
2142
554
36
4
12
0
Timor-Leste
2005 case notification by type of patientTotal notified: 3783
0.784
0.0506666667
0.0453333333
0.0026666667
0.0186666667
0.0986666667
Bhutan
Treatment resultsNew ss+, 2004 cohort (n = 375)
died, 5%
failure,
-
Five countries account for the majority of HIV burden in the RegionHIV Prevalence in the South-East Asia Region: 2007India 2,500,000Myanmar242,000
Thailand562,000Nepal 70,000Indonesia 193,000
-
HIV prevalence stable/decreasing in most countriesbut increasing in others.WHO 2007
Indonesia has the fastest growing HIV epidemic in Asia
-
Determinants for the frequency of HIV-associated TB in a community: SEAR600 million TB infectedTotal population of 1.6 billion4 million HIV infected TB/HIV co-infected3 million new cases per year TB epidemic being primarily driven by the 596 million TB infected non-HIV infected pool
-
Source: Tuberculosis in the South-East Asia Region, WHO/SEARO, March 2008
-
Source: Ministry of Health Union of Myanmar, December 2007
WHOLE STATUS
1609
805
HIV status of TB patientsFrom beginning of the Programme
Chart2
1113118
2066939
33012176
415157100
556199114
676242146
812289193
945333219
1063385264
1214434297
1322475323
1337490336
Cumulative Tested TB Patients
Cumualtive HIV +
Cumulative Referred to Enrol
Cumulative HIV Tested TB Patients,HIV + and Referred to Enrol IHC for 2006
Sheet1
MONTH | Freq Percent Cum.
------+-----------------------ENR | Freq Percent Cum.
1 | 123 8.6% 8.6%------+-----------------------HIVRES1
2 | 100 7.0% 15.7%1 | 28 7.3% 7.3%MONTH | 1 2 | Total
3 | 132 9.3% 24.9%2 | 27 7.0% 14.3%601 | 80 31 | 111-----------+---------------+------
4 | 91 6.4% 31.3%3 | 45 11.7% 26.0%602 | 57 38 | 95601 | 80 31 | 111
5 | 155 10.9% 42.2%4 | 27 7.0% 33.1%603 | 72 52 | 124602 | 57 38 | 95
6 | 133 9.3% 51.6%5 | 14 3.6% 36.7%604 | 49 36 | 85603 | 72 52 | 1241 | 18 5.4% 5.4%
7 | 150 10.5% 62.1%6 | 43 11.2% 47.9%605 | 99 42 | 141604 | 51 36 | 872 | 21 6.3% 11.6%
8 | 137 9.6% 71.7%7 | 55 14.3% 62.2%606 | 77 43 | 120605 | 104 42 | 1463 | 37 11.0% 22.6%
9 | 123 8.6% 80.4%8 | 30 7.8% 70.1%607 | 89 47 | 136606 | 77 43 | 1204 | 24 7.1% 29.8%
10 | 165 11.6% 92.0%9 | 47 12.2% 82.3%608 | 89 44 | 133607 | 89 48 | 1375 | 14 4.2% 33.9%
11 | 114 8.0% 100.0%10 | 38 9.9% 92.2%609 | 66 52 | 118608 | 89 45 | 1346 | 32 9.5% 43.5%
------+-----------------------11 | 30 7.8% 100.0%610 | 102 49 | 151609 | 67 53 | 1207 | 46 13.7% 57.1%
Total | 1423 100.0%------+-----------------------611 | 67 41 | 108610 | 104 49 | 1538 | 26 7.7% 64.9%
Total | 384 100.0%612 | 0 15 | 15611 | 68 41 | 1099 | 45 13.4% 78.3%
-----------+---------------+------10 | 33 9.8% 88.1%
Total | 858 478 | 133611 | 26 7.7% 95.8%
Jan1818Cumulative Tested TB PatientsCumualtive HIV +Cumulative Referred to Enrol12 | 13 3.9% 99.7%
Feb2139January111311855 | 1 0.3% 100.0%
Mar3776February2066939601 | 6 25 | 31-------+-----------------------
Apr24100March33012176602 | 12 26 | 38Total | 336
May14114April415157100603 | 13 39 | 52
June32146May556199114604 | 12 24 | 36
Jul47193June676242146605 | 17 25 | 42
Aug26219July812289193606 | 11 32 | 43
Sep45264August945333219607 | 15 33 | 48
Oct33297September1063385264608 | 9 36 | 45
Nov26323October1214434297609 | 16 37 | 53
Dec13336November1322475323610 | 18 31 | 49
1 | 18 5.4% 5.4%December1337490336611 | 23 18 | 41
2 | 21 6.3% 11.6%-----------+---------------+------
3 | 37 11.0% 22.6%Total | 152 326 | 478
4 | 24 7.1% 29.8%
5 | 14 4.2% 33.9%
6 | 32 9.5% 43.5%
7 | 46 13.7% 57.1%
8 | 26 7.7% 64.9%
9 | 45 13.4% 78.3%
10 | 33 9.8% 88.1%
11 | 26 7.7% 95.8%
12 | 13 3.9% 99.7%
55 | 1 0.3% 100.0%
-------+-----------------------
Total | 336
Chart5
858
478
HIV status of TB patientsFrom January (06) to November (06)
Chart6
Chart6
329
149
Referred to enrol IHC(TB/HIV co-infected patients,2006)
Chart3
35
3115
32468
20360
5720
116
20
Male
Female
Age group & sex distribution of TB/HIV coinfected patients
Chart10
195
378
146
27
1
12
46
Type of TB in TB/HIV coinfected patients
Sheet5
DiedNot have form 10RefuseDefaultOld ageBedriddenIn jailIVDUAway from homeTOARV from World VisionReasonNumber
CATZ5101Form 10 problem43
MHAM4231111Died20
AMTZ85411141Refuse with any reasons9
CMTZ35421Transferred to other townships5
Travellingin hospitalOn going processDefaulted during TB treatment3
112Bedridden2
Not in township TB register2
On going process2
Away from home1
In hospital1
In jail1
IVDU1
Old age1
Received ARV from World Vision1
Travel with anti-TB drugs1
Total93
1241
671
1912
1912
1336
0.6987447699
36
Sheet2
1 | 858 478 | 1336HIV ( - )HIV ( + )Referred to enrol IHCRemaining to enrol IHC
2 | 12 40 | 52858478329149
4 | 25 7 | 32
HIV ( - )HIV ( + )
1609805Referred to enrol IHC329
Remaining to enrol IHC149
152 326 | 478
AMTZ | 30 103 | 133
CATZ | 22 57 | 79
CMTZ | 36 58 | 94
MHAM | 31 61 | 92F | 5 15 68 60 20 6 0 | 174
PGTG | 33 47 | 80M | 3 31 324 204 57 11 2 | 632
-----------+---------------+------
Total | 152 326 | 478
0-1415-2425-3435-4445-5455-6465 and above
Male33132420357112
Female51568602060
AMTZ | 199 133 | 332
CATZ | 141 79 | 220
CMTZ | 221 94 | 315
MHAM | 181 92 | 273
PGTG | 116 80 | 1961 | 195NSS+195
-----------+---------------+------2 | 378NSS nge378
Total | 858 478 | 13363 | 146EP146
4 | 27Relapse27
5 | 1TAF1
6 | 12TAD12
Remaining to enrol IHC2557 | 46Others46
Referred to enrol IHC550
Sheet2
0
0
HIV status of TB patients From January (06) to November (06)
Chart9
0
0
HIV status of TB patientsFrom beginning of the programme
Chart1
0
0
Referred to enrol IHCTB/HIV co-infected patients from the beginning of program
Chart4
10528199
5836221
6230181
5722141
4733116
Enrollment of IHC program among TB/HIV co-infected patients by township
Referred IHC
Remaining
HIV ( - )
Chart7
6311019
174590
HIV +
HIV -
HIV status of TB patients by sex (From the beginning of programme)
Chart8
608
583
462
444
320
Number of HIV tested TB patients by township
Sheet4
1609807
2064
3922
HIV -
HIV +
HIV status of TB patients & their relatives
Chart11
652
153
Disease classification of TB/HIV coinfected patients
Sheet6
Registered adult TB patients1912
Tested for HIV1336Relatives tested84
TB/HIV co-infected patients478HIV infected47
HIV infected patients referred to IHC326
TBOUTCOME
HIVRES1 | 0 1 2 3 4 5 6 | Total
-----------+--------------------------------------------------+------
1 | 44 318 339 3 19 3 15 | 741
2 | 9 78 196 3 43 1 1 | 331
3 | 0 0 1 0 0 0 0 | 1CuredCompletedDefaultedDiedFailedT/outNot recordedTotal
-----------+--------------------------------------------------+------HIV ( - )31833931931544741
Total | 53 396 536 6 62 4 16 | 1073HIV ( + )78196343119331
Total396535662416531072
An expected value is < 5. Chi square not valid.
Chi square = 86.01
Degrees of freedom = 12Spouse52
p value = 0.00000000 6431
Referred IHCRemainingHIV ( - )HIV ( + )
Aungmyaethasan10528199227133
Chanmyathazi583622125794HIVRES1
Mahaaungmyae623018121192SEX | 1 2 3 | Total
Chanayethasan572214116379-----------+----------------------+------
Pyigyitagon473311614980F | 590 174 0 | 764
1007M | 1019 633 1 | 1653
-----------+----------------------+------
Total | 1609 807 1 | 2417
AMTZ | 30 103 | 133
CATZ | 22 57 | 79Aungmyaethasan608
CMTZ | 36 58 | 94Chanmyathazi583
MHAM | 31 61 | 92Chanayethasan462HIV +HIV -
PGTG | 33 47 | 80Mahaaungmyae444Male6311019
-----------+---------------+------Pyigyitagon320Female174590
Total | 152 326 | 478
AMTZ | 608 25.2% 25.2%
CATZ | 462 19.1% 44.3%199221181
CMTZ | 583 24.1% 68.4%303631
MHAM | 444 18.4% 86.8%1035861
PGTG | 320332315273
HIV -HIV +
A1 | 1609 807 1 | 2417TB patients1609807
2 | 20 64 0 | 84Spouse2064
4 | 39 22 0 |Child3922
PTB652
EPTB153
-
Characteristics of TB/HIV Patients in Thailand*
Median age 3480-90% with CD4 < 200High death rates, up to 43%-56% in some settings; Most deaths occur in first 2-3 monthsART during TB treatment reduces mortality dramatically: 4 -7% when provided ART (Akksilp, et. al., Emerg Infect Dis, 2007) 70% male; but HIV now altering the predominantly male pattern of TB disease in areas of high HIV prevalence
*multiple data sources
-
TB notifications: Average age and sex by province: Indonesia (2003)Source: Directorate-General of DC and EH, Ministry of Health , Indonesia
-
TB-HIV prevalence in SEAR
Source: *Ministries of Health, SEAR Member countries, 2007; Global TB Report WHO, 2008
-
Incidence of TB based on Nationwide ARTI survey: IndiaNorthWestEastSouthSource: RNTCP, India, MoH &FW, India; 2006
-
India: states with high HIV prevalence TAMILNADUANDHRAPRADESHMAHARSHTRAMANIPURNAGALANDGUJARATMADHYA PRADESHORISSAWESTBENGALBIHARJHARKHANDCHATTISGARHUTTAR PRADESHUTTARANCHALJAMMU &KASHMIRKERALARAJASTHANHARYANAPUNJABGOAHIMACHAL PRADESHDELHIDAMAN & DIUD&N HAVELISIKKIMMEGHALAYATRIPURAMIZORAMARUNACHALPRADESHASSAMLAKSHADWEEPMaharashtraAndhra PradeshKarnatakaTamil NaduQ: What is the likely impact of HIV on the future of TB control in India?Source: National AIDS Control Organization, MoH &FW, India; 2007
-
TB Infection HIV/TB Co-InfectionActive TB and HIVHIV InfectionTB ScreeningIPT DOTS CPTARTHIV/AIDS Care & SupportVCTCondomsSTDBlood SafetyHarm ReductionMTCTStrategy IIIReduce morbidity and mortality of HIV associated active TB and AIDSStrategy IIPrevent progression of latent TBStrategy IPrevent HIV Regional Strategic framework of interventions for TB/HIV interventionsStrategy IV: Strengthening the health systems response to TB/HIV
-
Building capacity for implementing TB/HIV collaborative activitiesModule 1: Introduction to TB/HIV Policies and ProgrammesModule 2: TB/HIV SurveillanceModule 3: TB/HIV InterventionsModule 4: TB/HIV Planning and ManagementModule 5: Translating knowledge and lessons learned into actionJoint programme managers meeting 2004, 2006, and 2008 Inter-country Training of trainers: 2005 and 2006In-country technical assistance missions
-
Progress at Country LevelFully integrated nation-wide implementation Thailand
Rapidly scaling up: India, Myanmar
Pilot projects: Indonesia and Nepal
Preparing for interventions:Bangladesh*, Bhutan, Sri Lanka, and Timor-Leste*HIV NGOs in Bangladesh are spearheading TB/HIV interventions; use of IPT, modifying the R & R formats, cross-referrals, provision of ART and CPT
-
Establish mechanisms of coordination
-
Decrease the burden of TB in PLHA
-
Decrease the burden of HIV in TB patients
-
Increasing Acceptance of HIV testing among TB Patients
Percent of patientsSource: ODPC 7, Ubon Ratchatani Province, Thailand
-
TB patients tested and referred to IHCs Myanmar Source: Ministry of Health, Union of Myanmar, November 2007
total
2337
1372
Chart1
1077201326
2428558819
2666558891
2839558940
30705671018
31995841057
33826071120
35676201181
37486591241
39406951308
40787511355
42288291401
43468561465
Tested
Referred to enrol
HIV+
Year/Month
Number
Sheet1
MONTH | Freq Percent Cum.
------+-----------------------ENR | Freq Percent Cum.
1 | 123 8.6% 8.6%------+-----------------------
2 | 100 7.0% 15.7%1 | 28 7.3% 7.3%601 | 86 37 | 1233131
3 | 132 9.3% 24.9%2 | 27 7.0% 14.3%602 | 60 40 | 1003869
4 | 91 6.4% 31.3%3 | 45 11.7% 26.0%603 | 75 57 | 13252121
5 | 155 10.9% 42.2%4 | 27 7.0% 33.1%604 | 53 38 | 9136157
6 | 133 9.3% 51.6%5 | 14 3.6% 36.7%605 | 107 48 | 15542199
7 | 150 10.5% 62.1%6 | 43 11.2% 47.9%606 | 81 52 | 13343242
8 | 137 9.6% 71.7%7 | 55 14.3% 62.2%607 | 97 53 | 15048290
9 | 123 8.6% 80.4%8 | 30 7.8% 70.1%608 | 89 48 | 13745335
10 | 165 11.6% 92.0%9 | 47 12.2% 82.3%609 | 68 55 | 12353388
11 | 114 8.0% 100.0%10 | 38 9.9% 92.2%610 | 111 54 | 16549437
------+-----------------------11 | 30 7.8% 100.0%611 | 70 44 | 11441478
Total | 1423 100.0%------+----------------------------------+---------------+------478
Total | 384 100.0%Total | 897 526 | 1423
Jan2525TestedReferred to enrolHIV+
Feb265120051077201326MONTH | 1 2 | Total
Mar3990357200624285588191351493-----------+---------------+------HIVRES1
Apr24114007,Jan266655889123872601 | 80 31 | 111MONTH | 1 2 | Total
May25139007,Feb283955894017349> 72.1% 27.9% > 8.4%-----------+---------------+------
June32171907,Mar3070567101823178| 9.5% 6.6% |601 | 80 31 | 111
Jul332041707,Apr3199584105712939602 | 57 38 | 95> 72.1% 27.9% > 8.3%
Aug362402307,May3382607112018363> 60.0% 40.0% > 7.2%| 9.3% 6.5% |
Sep372771307,June3567620118118561| 6.8% 8.1% |602 | 57 38 | 95
Oct313083907,July3748659124118160603 | 72 52 | 124> 60.0% 40.0% > 7.1%
Nov183263607,Aug3940695130819267> 58.1% 41.9% > 9.4%| 6.6% 7.9% |
3265607,Sep4078751135513847| 8.5% 11.0% |603 | 72 52 | 124
7807,Oct4228829140115046604 | 48 36 | 84> 58.1% 41.9% > 9.3%
2707, Nov4346856146511864> 57.1% 42.9% > 6.4%| 8.4% 10.9% |
0| 5.7% 7.6% |604 | 51 36 | 87
601 | 80 31 | 1110605 | 99 42 | 141> 58.6% 41.4% > 6.5%
9
17
602 | 57 38 | 9523> 70.2% 29.8% > 10.7%| 5.9% 7.5% |
603 | 72 52 | 12410611061322322| 11.7% 8.9% |605 | 104 42 | 146
604 | 51 36 | 87111117231353606 | 77 43 | 120> 71.2% 28.8% > 10.9%
605 | 104 42 | 14695126738391> 64.2% 35.8% > 9.1%| 12.1% 8.8% |31
606 | 77 43 | 120124139152443| 9.1% 9.1% |606 | 77 43 | 12038
607 | 89 48 | 13786147736479607 | 89 47 | 136> 64.2% 35.8% > 9.0%52
608 | 89 45 | 134142161942521> 65.4% 34.6% > 10.3%| 9.0% 9.0% |36
609 | 67 53 | 120120173943564| 10.5% 10.0% |607 | 89 48 | 13742
610 | 104 49 | 153136187547611608 | 87 43 | 130> 65.0% 35.0% > 10.3%43
611 | 68 41 | 109133200844655> 66.9% 33.1% > 9.9%| 10.4% 10.0% |48
-----------+---------------+------118212652707| 10.3% 9.1% |608 | 89 45 | 13445
Total | 858 478 | 1336151227749756609 | 66 52 | 118> 66.4% 33.6% > 10.0%53
108238541797> 55.9% 44.1% > 9.0%| 10.4% 9.4% |49
15240015812| 7.8% 11.0% |609 | 67 53 | 12041
236263672884610 | 102 48 | 150> 55.8% 44.2% > 9.0%478
172280849933> 68.0% 32.0% > 11.4%| 7.8% 11.1% |
| 12.1% 10.2% |610 | 104 49 | 153
611 | 67 40 | 107> 68.0% 32.0% > 11.5%
> 62.6% 37.4% > 8.1%| 12.1% 10.3% |
| 7.9% 8.5% |611 | 68 41 | 109
-----------+---------------+------> 62.4% 37.6% > 8.2%
Total | 844 472 | 1316| 7.9% 8.6% |
| 64.1% 35.9% |-----------+---------------+------
Total | 858 478 | 1336
| 64.2% 35.8% |
Chart4
845571157104
835594213163
728435143104
66544513893
51131513177
Registered adult TB
VCCT accepted & tested
Co-infected
Referred to enrol
Township
Number
VCCT status of (Jan 2005 to Nov 2006) registered adult TB patients
Sheet2
MHAMCATZAMTZPGTGCMTZTownshipRegistered adult TBVCCT accepted & testedCo-infectedReferred to enrol
Registered adult TB7286658355118453584CMTZ845571157104
VCCT accepted & tested4234415773135602314AMTZ835594213163
Co-infected143138211129153774MHAM728435143104
Referred to enrol1049316376102538CATZ66544513893
PGTG51131513177
MHAMCATZAMTZPGTGCMTZ
Registered adult TB728665835511845
VCCT accepted & tested435445594315571
Co-infected143138213131157
Referred to enrol1049316377104
Chart2
47029586
434305124
40324986
33920773
26618574
Registered adult TB
VCCT Accepted & Tested
HIV +
VCCT Accepted & HIV Tested Adult TB Patients(2006 January to November)
Chart3
671
1241
Proportion of VCCT accepted & HIV tested TB patients for 2006
Sheet4
MHAMCATZAMTZPGTGCMTZVCCT Accepted & Tested23372005/62580243
Registered adult TB7286658355119703709No Tested1372
VCCT Accepted & Tested4274465843165642337
1372
Sheet6
MHAM(05)CATS(05)AMTS(05)PGTG(05)CMTZ(05)Registered adult TBVCCT accepted & testedRegistered adult TBVCCT accepted & tested
0-141048799128136AMTZ401272CMTZ470295
15-64325326401245375CMTZ375265AMTZ434305
65 and above2222351429CATZ326234MHAM403249
MHAM325174CATZ339207
MHAM(06)CATS(06)AMTS(06)PGTG(06)CMTZ(06)PGTG245128PGTG266185
0-141071151369012219121241671
15-64403339434266470
65 and above2417371418
MHAMCATZAMTZPGTGCMTZregtested
2005325326401245375167216721073
2005 TESTED174234272128265107319121241
2006403339434266470191235842314
2006 TESTED249207305185295124119
2333
2004 TESTED247331965.0948660714
35842416
67.4107142857807
1609
MHAMCATZAMTZPGTGCMTZ
Registered adult TB728665835511845358435842414
VCCT accepted & tested4354455943155712360
Co-infected143138213131157782
Referred to enrol1049316377104541
MHAMCATZAMTZPGTGCMTZ
Registered adult TB3782953842694151741
VCCT accepted & tested3262603122493651512
Co-infected1087711080114489
Referred to enrol2722341625124
Amtzcmtzmhamcatzpgtg
jan4935553033
feb4845383428
mar5564643635
apr4347383036
may5158673137
june5060434940
july3853274432
aug5053464128
sep3947323419
oct4336353429
4664984453633172089
Sheet5
MHAM(05)CATS(05)AMTS(05)PGTG(05)CMTZ(05)
0-141048799128136
15-64325326401245375
65 and above2222351429
MHAM(06)CATS(06)AMTS(06)PGTG(06)CMTZ(06)MHAM(06)CATS(06)AMTS(06)PGTG(06)CMTZ(06)
0-14107115136901222005347348436259404
15-644033394342664702006>14 year460401506308525
65 and above24173714182007 aug378295384269415
11851044132683613445735
MHAMCATZAMTZPGTGCMTZ
2005325326401245375
2005 TESTED174234272128265AMTZ35869457272
200640333943426647094769045305
2006 TESTED249207305185295CATZ39717450234
60585534207
2004 TESTED24733CMTZ40878058265
66828166295
MHAM7417848174
71716542249
PGTG13363841128
pt2415notr3646545827185
tyear2333treat2379
82
36
46235742361
29
R12417NO PT27
NO TB2
2334
27
23612361
Sheet3
MHAM(05)MHAM(06)CATS(05)CATS(06)AMTS(05)AMTS(06)PGTG(05)PGTG(06)CMTZ(05)CMTZ(06)Registered adult TBVCCT Accepted & TestedHIV +
0-14104107871159913612890136122CMTZ47029586
15-64325403326339401434245266375470AMTZ434305124
65 and above22242217353714142918MHAM40324986
CATZ33920773
1912PGTG26618574
19121241443798
Current selection: (NOTREAT=2) AND (TYEAR>60)NO testedVCCT Accepted & Tested
1116711241
TYEAR442
TOWNSHIP | 61 62 63 64 | Total
-----------+-----------------------------+------MHAMCATZAMTZPGTGCMTZ1336
AMTZ | 94 75 90 45 | 30453253264012455001239
CATZ | 60 58 55 33 | 206640333943426647097
CMTZ | 66 82 81 66 | 2957286658355119701239
MHAM | 71 71 65 42 | 249673
PGTG | 46 54 58 27 | 1851912
-----------+-----------------------------+------
Total | 337 340 349 213 | 1239
MHAMCATZAMTZPGTGCMTZ
Registered adult TB7286658355119703709
Chi square = 14.09VCCT Accepted & Tested42744658431656423371912
Degrees of freedom = 121241
p value = 0.29472916671
403
Current selection: ((NOTREAT=2) AND (TYEAR>60)) AND (TOWNSHIP="AMTZ")339
434
MONTH470
TYEAR | 601 602 603 604 605 606 607 6081646
-----------+--------------------------------------------------------1912
61 | 24 34 25 6 4 1 0 0266
62 | 0 0 0 17 26 19 6 2
63 | 0 0 0 0 0 0 21 31
64 | 0 0 0 0 0 0 0 0
-----------+--------------------------------------------------------
Total | 24 34 25 23 30 20 27 33
MONTH
TYEAR | 609 610 611 | Total
-----------+----------------------+------
61 | 0 0 0 | 94
62 | 4 0 1 | 75
63 | 30 8 0 | 90
64 | 0 19 26 | 45
-----------+----------------------+------
Total | 34 27 27 | 304
An expected value is < 5. Chi square not valid.
Chi square = 705.17
Degrees of freedom = 30
p value = 0.00000000
-
(%)
-
Intensified TB/HIV package for high HIV burden statesIntensified TB/HIV packageRoutine offer of VCT to all TB patientsOne page guidance tool developedProvision of CPT to HIV infected TB ptsProgrammatic implementation of shared confidentiality of HIV status in HIV high burden statesCPT at DOTS centres by RNTCPHIV status, CPT, and ART integrated into TB programme records and reportsMizoramPondicherryGoa9 states; 158 districts;317 million population
-
Intensified TB/HIV package- Expanded RNTCP recording & reportingCase-finding and treatment outcome reportsTB Treatment cards with HIV status, CPT, ARTTB registers with HIV status, CPT, ART
-
Expansion of HIV counseling and testing services in IndiaThe RNTCP of India has 12,000 microscopy centres and over 200,000 centres offering TB treatment
-
Challenges in Linking HIV-infected TB Patients for Care and Support* Excludes 94 patients already on ART at TB diagnosis
-
Slow expansion of HIV services is the rate limiting step.
--SEAR NTP Managers , November 2006
-
Issues (2) Are the programs equipped?ProgrammaticLevel at which TB and HIV services are delivered (HIV: centralized, TB: decentralized to sub-district level)Availability of diagnostics and drugs: HIV test kits, TB cultures, X-rays limitedAvailability of trained, skilled and motivated personnel (both programs)Existence of plans, with clear indicators and targets (TB, HIV and general health services)Operational systems for cross-referral, linkageslevel of involvement and approaches of NGOs and private providers in the two programmesOtheradministrative, ethical, social, etc.
-
Issues: (3) A firm footing??
Relative to the problem---
Attention at higher policy level, to TB/HIV as an issue; TB programs still the primary drivers ?
Mandated well-functioning TB-HIV coordinating/technical working groups with representation from all concerned sectors at the planning and operational level?
TB a priority for national HIV/AIDS programmes?
Health system constraints?!
Mindsets!!.. also,
stigmatization/fear on part of health workers
-
Issues (4): Implementation
Surveillance, monitoring and evaluationTB-HIV SurveillanceNeed to move towards routine referral and reporting. In the meantime, what surveillance strategies, in light of heterogeneous HIV prevalence in most countries? Monitoring, EvaluationMost countries yet to firmly adopt indicators and to set targets that are relevant to their programmesJoint M and E just beginningDecreasing the burden of TB in PLHAIntensified case findingNeed to establish TB screening into longitudinal care among PLWHAMost health providers still not thinking TB among PLWHA and other high risk groupsIsoniazid preventive therapy Most question feasibility; others worry about amplifying INH resistance Infection controlLargely not in place; lack policies, clear operational guidelines for what to do in programme context
-
Issues(5)Implementation
Decreasing the burden of HIV in TB patientsRoutine cross-referralLimited VCT centres; Limited availability of HIV test kitsIncreased burden on available (yet very limited) VCT centresSelective referral in low HIV settings(missed opportunities)
HIV screening of TB suspectssheer numbers of non-HIV infected; yield seen as low vs increased load on system; inviting unnecessary stigmatizationHIV preventionLimited to limited VCT, HIV treatment facilities, and TB-HIV pilot/program sitesCotrimoxazole (CPT) and Antiretroviral therapy (ART)Policy for CPT exists; practice highly variable Policy for ART in line with international guidelines; CD4 and ART available only at secondary and tertiary care facilitiesWidespread (mis) use of both first and second line ART and ATT in private sector Use of Rifabutin ? Secondline ART? Second-line ATT?
-
The Way Forward: ImplementationEnsure adequate capacity (human, financial resources, infrastructure)Focus on implementation!!Urgently address programmatic challenges in ensuring diagnosis and treatment Expand best practice interventions for ICF, IC and IPT with HIV programmes as they scale upEngage more with private providers and communitiesAddress sociological challenges: stigma, high-risk behaviours; psycho-social support systemsImprove surveillance, monitor and evaluate interventions and their impact
-
The way forward: establish a firm foundation
Advocate at the highest levels for commitment to addressing TB/HIV based on evidence (need better surveillance)
Prioritize TB on the agenda of national HIV/AIDS programmes as they scale up not just another opportunistic infection
Establish a well-functioning Regional level and national TB-HIV technical committees, with representation from all stakeholders and partners
Help address health system constraints
-
TB/HIV targets: SEA Regional Strategic Plan for TB Control, 2006-2015
IndicatorCurrentlyBy 2010National coordinating bodies/technical working groups established5/11 countriesAll countries
Proportion of newly diagnosed TB patients tested for HIV70%Proportion of VCT attendees screened for TBLargely unknown>70%Proportion of PLWHA with active TB receiving ATTUnknown>85%Proportion of TB patients with HIV eligible for ART, who receive ART80%
Of 1389 HIV-infected TB patients registered in 2005 in the Active Surveillance Network, the median age was 34 (range: 1, 82) and almost 70% were male. Of 931 (67%) with CD4 counts recorded, 83% had CD4 < 200 cells/mm3; only 9% had CD4 > 300 cells/mm3. In 999 HIV-infected TB patients registered in 2005 from Region 10, 515 (52%) had CD4 recorded; of these, 93% had CD4 < 200 cells/mm3 and only 5% had CD4 > 300 cells/mm3. In the DCT project conducted in 12 hospitals throughout Thailand in 2006, 91% of 45 HIV-infected TB patients had CD4 < 200 cells/mm3. A large proportion of HIV-infected TB patients were diagnosed with HIV before their TB diagnosis, 814 (59%) of 1389 patients in the Active Surveillance Network and 87 (47%) of 185 in the DCT project. Nationally, treatment outcomes stratified by HIV status were not available from 2001-2005. In the Active Surveillance Network, the treatment success rate was 57% in 1335 HIV-infected TB patients compared with 76% in 3012 HIV-uninfected TB patients and 61% in 1261 HIV-unknown TB patients (p