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5 th DOTS Expansion Working Group Meeting, Paris, October 28, 2004 Tuberculosis and HIV - Future Directions

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

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5 th DOTS Expansion Working Group Meeting, Paris, October 28, 2004 Tuberculosis and HIV - Future Directions

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  1. 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

  2. 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

  3. 4th DEWG: Rationale for Joint TB/HIV Activities • HIV drives TB incidence and mortality in high HIV prevalence areas

  4. Estimated TB incidence vs HIV prevalence 800 600 Estimated TB incidence 400 (per 100K, 1999) 200 0 0.0 0.1 0.2 0.3 0.4 HIV prevalence, adults 15-49 years

  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

  6. Regional TB incidences

  7. 30 30 25 25 20 20 15 15 10 10 5 5 0 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Epidemic in sub-Saharan Africa 1985−2003 Millions Number of people living with HIV and AIDS % HIV prevalence, adult (15-49) % HIV prevalence adult (15-49) Year Source: UNAIDS/WHO, 2004 2004 Report on the Global AIDS Epidemic (Fig 5)

  8. 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

  9. New imperatives • Standard of care • Human rights based approach • Patient-centred care • MDG targets include prevalence and mortality

  10. TB/HIV Collaborative Activities Establish 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 settings Decrease 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

  11. 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 Establish mechanisms for collaboration

  12. 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 tuberculosis in people living with HIV/AIDS

  13. 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 Decrease the burden of HIV in tuberculosis patients

  14. 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

  15. 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

  16. Mandela urges action to fight TBBy Chris Hogg BBC Bangkok 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. 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. Mandela sounds alarm on TB "death sentence" in AIDS war By Darren Schuettler

  17. 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

  18. "…all member states should embrace and scale up implementation of collaborative TB/HIV activities." African Union, Addis Ababa, September 2003

  19. 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

  20. "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

  21. 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

  22. 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

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