4th DOTS Expansion Working Group, The Hague, October 8, 2003

1. 4th DOTS Expansion Working Group, The Hague, October 8, 2003 Interim Global Policy on Collaborative Activities Paul Nunn GLOBAL PARTNERSHIP TO STOP TB

2. Logic • Joint TB/HIV interventions, jointly delivered, are needed to control HIV-associated TB, expand DOTS, and indeed, to control HIV

3. Principles • “Two diseases, one patient” • Patient focused care delivery for both diseases at the same time • There is an ongoing catastrophe, therefore • No more “projects” • Immediate scale up of what works(WHO Strategic and Technical Advisory Group 2001) • Revise as more evidence becomes available • No separate programme • Collaborative activities add to existing TB and HIV/AIDS control strategies • Policy needs to be global

4. Sequence • Policy is built on field experience with ProTEST and other TB/HIV pilot projects, Rwanda, Kenya, Thailand etc. • Strategic framework to decrease burden of TB/HIV • Complete rationale, analysis and menu • What could be done • Guidelines for implementing collaborative TB and HIV programme activities • How to organise at national and district level • Interim policy on collaborative TB/HIV activities • What should be done by countries

5. Process for Interim Policy • Under auspices of Global TB/HIV Working Group • Iterative drafting process by: • technical experts from TB and HIV, • health management policy makers, • persons living with HIV and their advocates, • international and national TB and HIV programme managers, and donor agencies

6. F. Adatu (NTP/Uganda) K. Bergstrom (WHO/STB) L. Blanc (WHO/STB) H. Getahun (WHO/STB) P. Godfrey-Fausset (UK) J. Gorkom (KNCV/Namibia) A. Harries (NTP/Malawi) M. Harrington (TAG/USA) G. Loth (WHO/HIV) B. Miller (CDC/USA) Y. Mukadi (FHI/USA) W. Nkhoma (WHO/AFRO) P. Nunn (WHO/STB) P. Pronyk (S. Africa) P. Ramon-Pardo (WHO/AMRO) J. Perriens (WHO/HIV) A. Reid (WHO/STB) Y. Ru-Lo (WHO/SEARO) F. Scano (WHO/STB) C. Sozi (UNAIDS/S. Africa) J. Stover (TFGI/USA) J. Yanai (Thailand) Members of Ad hoc Writing Committee

7. Core writers • H. Getahun (WHO/STB) • J. Gorkom (KNCV/Namibia) • A. Harries (NTP/Malawi) • M. Harrington (TAG/USA) • P. Nunn (WHO/STB) • J. Perriens (WHO/HIV) • A. Reid (WHO/STB) • M. Vitoria (WHO/HIV)

8. Goal and Objectives • Goal • to decrease the burden of TB and HIV in dually affected populations. • Objectives • (1) to establish the mechanisms for collaboration between TB and HIV/AIDS programmes • (2) to decrease the burden of TB in PLWHA • (3) to decrease the burden of HIV in TB patients.

9. 1. To establish the mechanisms for collaboration between TB and HIV/AIDS programmes A.1. A co-ordinating body for TB/HIV activities effective at all levels A.2. Surveillance of HIV prevalence among tuberculosis patients • separate guidelines in final draft A.3. Joint TB/HIV planning A.4. Monitoring and evaluation • separate guidelines in final draft

10. 2. To decrease the burden of TB in PLWHA B.1. Intensified TB case finding B.2. Isoniazid preventive therapy B.3. TB infection control in care and congregate settings

11. 3. To decrease the burden of HIV in TB patients C.1. HIV testing and counselling C.2. HIV prevention methods C.3. Cotrimoxazole preventive therapy C.4. HIV/AIDS care and support C.5. Antiretroviral therapy

12. C.5. Antiretroviral therapy. Antiretroviral therapy (ART) improves the quality of life and has great survival benefits for PLWHA. Lowering the viral load with ART may also reduce the likelihood of transmitting HIV to others. It is a lifelong treatment and requires high adherence rates to minimise the development of drug resistance. Recommendations 1. ART should be offered to all eligible HIV positive tuberculosis patients, taking into consideration the possibility of drug interactions and eligibility criteria for ART in each country 2. TB and HIV/AIDS programmes should create the mechanism to provide ART to HIV positive TB patients. There is evidence that ART can reduce the incidence of TB in HIV positives by more than 80% (41, 42). However, for ART to prevent the significant fraction of TB cases, initiation of ARV early in the course of HIV infection and a high rate of compliance are required (43). The initiation of ARV in HIV infected TB patients can result in the transient worsening of TB symptoms and signs in up to 30%of the patients in the developed world (44, 45). Expert opinion (36, 44, 46) and observational studies (40, 47,48) proposed that directly observed treatment programmes of TB can be used for ARV delivery. There have been counteracting opinions for this strategy for scarcity of evidence (49) and poor infrastructural capacity of the existing TB control programmes (44).

13. Thresholds to collaborative TB/HIV activities

14. Targets for collaborative TB/HIV activities • By 2005, all Category I and II countries will have established at least a national TB/HIV co-ordinating body. • By 2007, all Category I and II countries will have established a system for HIV surveillance among TB patients.

15. Next Steps • Revision of near final draft by ad hoc committee underway • Review and endorsement by Core Group of the TB/HIV Working Group underway • Publication WHO December 2003 • together with: • Guidelines for surveillance of HIV among TB patients • Guidelines for Monitoring and Evaluation of Collaborative TB/HIV Activities

16. The 3 by 5 Initiative

17. What is the “3 by 5” Initiative? • 3 million PLWHA on antiretroviral therapy by 2005 • Major priority of WHO • Overall goal: universal access to treatment • 6 product areas: • simplified treatment guidelines • country emergency teams • uniform monitoring and evaluation standards and tools • training and capacity development • AIDS drugs and diagnostics facility • advocacy and resource mobilisation • Outline strategy for Dec 1st - World AIDS Day

18. Current status of 3 by 5 • 3 x 5 core group formed in WHO • WHO Internal Steering Group • External Partners Group • 8 working groups • Country teams being formed eg Kenya • Major consultation with RAs, WRs, Montreux this week

19. What will 3x5 mean for TB? • Aims: • Strengthen joint TB/HIV activities • Better care for HIV + TB patients • TB prevention • Principles: • TB support to ARV delivery • HIV services to support TB care • More activities requires more resources

20. What will 3x5 mean for TB? • Strategies: • Political commitment • Support for joint HIV/TB collaborative mechanisms • Secure drug supply • Centralised national procurement based on patient numbers • ADDF • Efficient diagnosis • HIV testing available for TB patients • Simplified, standardised treatment • Standard “TB friendly” regimens, with 2nd line, • DOT? To be decided • Recording and reporting • Standard registers and forms • ?Quarterly reporting

21. How will it be done? TBD • National level central unit • Regional HIV/AIDS officer • District HIV/AIDS officers • Distribute drugs • Assist/supervise general health services • Recording, reporting, stats

22. Possible HIV/TB structure and referral flows at district level VCT/TC PMTCT+/- TB Clinic +HIV testing Start ARVs Post TB Rx ARV management Monitor during ARV treatment AIDS ARV Clinic/Day Care Centre Home based care programme OPD GeneralWards

23. “Two Diseases, One Patient” “Let’s go together”