Updates on TB/HIV burden

WHO European Region

2015 data

18th Wolfheze workshops / 15th NTP managers meeting,

31 May – 02 June 2017

Dr Andrei DADU

Technical officer,

Joint TB, HIV/AIDS and Hepatitis Programme

HIV AND TB REMAIN A DEADLY SYNERGY

CHALLENGES:© Maxim Dondiuk http://maximdondyuk.com/projects/tb-epidemic-in-ukraine

3,6

0,540

1

2

3

4

5

6

7

8

9

10

2000 2005 2010 2015

Rat

e p

er 1

00

00

0 p

op

ula

tio

n

Estimated TB/HIV mortality rate Estimated TB mortality rate

3.6% annual increase

between 2010-2015

-8.3% annual decline

between 2010-2015

Impressive decline in TB mortality combined with growing

burden of TB/HIV mortality

3

36

0

10

20

30

40

50

60

70

80

2000 2005 2010 2015

Rat

e p

er 1

00

00

0 p

op

ula

tio

n

Estimated TB/HIV rate Estimated TB incidence rate

-4.5% annual decline

between 2010-2015

WHO European Region has fastest decline in TB incidence,

however … still growing TB/HIV co-infection

6.2% annual increase

between 2010-2015

Main impact indicatorsTB and TB/HIV mortality, EUR, 2000-2015 TB and TB/HIV incidence, EUR, 2000-2015

Top 10 high TB/HIV countries;* Europe, 2015

RussiaUkraine

Uzbekistan (2010)

Portugal

Rep Moldova

Kazakhstan

Romania

United KingdomFrance

Spain

0

20

40

60

80

100

120

140

160

180

200

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75

Esti

mat

ed T

B in

cid

ence

per

10

0,0

00

po

pu

lati

on

Reported new HIV cases per 100,000 population

*10 TB/HIV high-burden countries estimated contributing to 90% of the total 27,000 TB/HIV new cases

9,00011,000

4

Source: Tuberculosis surveillance and monitoring in Europe 2017: ECDC / WHO Europe.

TB/HIV prevalence increased in most of HPCs

Countries with the higher TB/HIV co-

infection shows much faster

increase of HIV prevalence.

Estonia is only country showing

decline in HIV

Ukraine

Latvia

Estonia

Russia

Armenia

Moldova

Uzbekistan

Belarus

Lithuania

Kyrgyzstan

Georgia

Kazakhstan

Tajikistan

Romania

Azerbaijan

Turkey

Bulgaria

Turkmenistan

0,0 5,0 10,0 15,0 20,0 25,0HIV prevalence among TB patients (%)

20102015

HIV prevalence among TB patients in 2011 and 2015 in 18 HPCs of WHO European Region

HIV co-infection among TB patients continues to rise in Europe, 2015

5,56,1

7,8 8,0

9,071,3

77,985,9 88,9 88.0

0,0

2,0

4,0

6,0

8,0

10,0

0

20

40

60

80

100

2011 2012 2013 2014 2015

%%

HIV testing coverage and co-infection among TB patients in WHO European Region, 2011-2015

% HIV among TB cases % of known HIV status

Source: Tuberculosis surveillance and monitoring in Europe 2017: ECDC / WHO Europe. 22%17%

12%10%

9%9%

6%6%

4%3%

3%3%3%3%

2%1%

0%

9%9%

UkraineLatvia

EstoniaRussia

ArmeniaMoldova

UzbekistanBelarus

LithuaniaKyrgyzstan

GeorgiaKazakhstan

TajikistanRomania

AzerbaijanTurkey

BulgariaTurkmenistan

European…Subtotal 18 HPC

% HIV among TB patients, 18 HPC, 2015

HIV and TB create a deadly combination (cascade analysis)

88%

61%36% 41%

HIV testingcoverage

TB/HIV casedetection

ARV coverage treatment succes

HIV case detection among TB and ARV* treatment coverage , WHO European Region, 2015

* No data from RUS (40% of all TB/HIV detected cases) otherwise 62%

No data from RUS (30% of all TB/HIV on treatment)

CPT ?

Source: Tuberculosis surveillance and monitoring in Europe 2017: ECDC / WHO Europe.

• About 88% of known HIV status

• About 27 thousands estimated TB/HIV cases about

16.5 thousands (61%) were detected

• Of which only 5.8 thousands (35%)were offered antiretroviral treatment

• treatment success remain low = 41%

77

7

4

5

7

41

21

28

7

3

Success

Died (A6)

Failed

Lost-to-follow up

Not evaluated*

HIV negative

HIV positive

Treatment outcomes (%) of new and relapsed TB cases desegregated by HIV status

* Not evaluated: “transferred out”, “still on treatment”, others

TB treatment results by HIV status; WHO European Region

8

Source: WHO Europe / ECDC. Tuberculosis surveillance and monitoring in Europe 2017

New HIV infections; UNAIDS region, 2010-2015

UNAIDS. AIDS by the numbers 2016 (http://www.unaids.org/sites/default/files/media_asset/AIDS-by-the-numbers-2016_en.pdf)

New

HIV

infe

ctio

ns

in p

eop

le >

15

yea

rs (

/10

00

)

9

AIDS-indicative diseases; WHO Europe, 2015

ECDC/WHO Europe: HIV/AIDS surveillance in Europe 2015. Stockholm: ECDC, 2016

36%

20%

12%

10%

8%

3%

3%

3%

2%

2%

Pulmonary TB

Wasting syndrome

Extrapulmonary TB

Candidiasis (oesophagus)

Pneumocystis pneumonia

Encephalopathy

Pneumonia

Toxoplasmosis (brain)

Candidiasis (respiratory)

Isosporiasis

26%

21%

13%

9%

8%

7%

5%

5%

4%

3%

Wasting syndrome

Pulmonary TB

Pneumocystis pneumonia

Candidiasis (oesophagus)

Encephalopathy

Pneumonia

Toxoplasmosis (brain)

Kaposi sarcoma

Extrapulmonary TB

Cytomegalovirus

28%

15%

13%

10%

8%

7%

6%

6%

4%

3%

Pneumocystis pneumonia

Candidiasis (oesophagus)

Kaposi sarcoma

Wasting syndrome

Toxoplasmosis (brain)

Extrapulmonary TB

Cytomegalovirus

Pulmonary TB

Encephalopathy

Leukoencephalopathy

10

HIV cascade on TB prevention; WHO Europe, 2015

PLHIV = people living with HIV; IPT = isoniazid preventive therapy

Sources: ECDC/WHO Europe . Tuberculosis surveillance and monitoring in Europe 2017 (unpublished draft); https://extranet.who.int/tme/generateCSV.asp?ds=notifications

220,000

153,407

28,130 26,33510,037

0

20

40

60

80

100

Perc

enta

ge

10/53 countries reported(1/30 EU/EEA, 9/23 non-EU/EEA)

11

Collaborative framework for TB, HIV, VH

PLHIVPrisonersIDUMigrantsHealth workers

Mechanisms for integrated delivery

Coordinating body

Joint surveillance

Joint planning

Joint monitoring

Reduce the burden of TB

Case-finding

Prevention

Treatment

Infection control

Reduce the burden of HIV and VH

Testing and counselling

Prevention

Continuum of care

Treatment

Long-term facilities

MSMSex workersBlood transfusedMTCT

TB contactsSilicia exposureDiabetes mellitus

Alcohol harmful useTobacco smokingTransplantation hemodialysis

Heterosexual HIV contact

12

Towards integrated care (TB, HIV, IUD, hepatitis)

2012 2013 2014 20162015

13

TB action plan: activities related to HIV

1.B.3 WHO/partners, will help NTPs to develop strategies to maximize the

benefits of rapid diagnostic tools for hard-to-reach and vulnerable

populations (by 2017)

1.C.3 Member States (MS) will ensure the rational, safe and effective

introduction of TB medicines according to the most recent WHO policy

guidance (no later than 2016)

1.D.6 WHO/partners will assist MS in establishing coordination mechanisms at

national/regional levels to facilitate the delivery of integrated TB & HIV

services (by 2018).

1.D.2 MS will ensure that all TB patients have access to HIV counselling and

testing supported by national HIV and TB guidelines (no later than 2016).

1.D.3 MS will ensure that all TB/HIV patients have access to early and monitored

(as per most recent WHO recommendations) ART and CPT (no later than

2016).

TB and HIV action plans for WHO Europe 2016-2020

14

TB and HIV action plans for WHO Europe 2016-2020

HIV action plan: strategic direction related to TB

Strategic direction 3: Delivery for equity

Enabling environment and optimization of service delivery. Continuum of care also

relies on the integration with other services focusing on comorbidities and related

health conditions such as TB, MDR-TB and XDR-TB.

15

Acknowledgements: Member States

ECDC and WHO/HQ

RO and COs colleagues

eurotb@who.int

https://twitter.com/WHO_Europe_TB