Extensively Drug Resistant XDR TB and HIV treatment acceleration What needs to be done

2. What is XDR-TB? Definition = Multi-drug resistant TB (MDR-TB) plus resistance to any fluoroquinolone and at least 1 of the 3 injectable second line drugs (Capreomycin, Kanamycin, Amikacin) MDR-TB is resistance to at least INH and Rifampcin, the two most effective first line anti-TB drugs. By-product of weak and ineffective TB control efforts and collaboration between TB and HIV control programmes.

3. TB treatment and drug resistance(with no HIV) Resistance Absent MDR-TB XDR-TB Cure rate Virtually 100% Up to 80% Up to 60%

4. TB drug resistance scenario(always with worse outcomes for PLHIV)

5. Estimated MDR TB Cases by Regions

9. Burden of TB on ART program 67% history of TB or prevalent TB 15% referred on TB treatment 10% have newly diagnosed TB at ART screening

10. Burden of TB on ART programBonnet et al AIDS 2006, 20:1275�1279

11. There is ample evidence on the impact of TB on ART programs The emergence of XDR TB is yet another call for effective collaboration between TB and HIV control programmes to deliver collaborative TB/HIV activities.

12. Collaborative TB/HIV activities A. Establish the mechanism for collaboration A.1. TB/HIV coordinating bodies A.2. HIV surveillance among TB patient A.3. TB/HIV planning A.4. TB/HIV monitoring and evaluation B. To decrease the burden of TB in PLWHA B.1. Intensified TB case finding B.2. Isoniazid preventive therapy B.3. TB infection control C. To decrease the burden of HIV in TB patients C.1. HIV testing and counselling C.2. HIV preventive methods C.3. Cotrimoxazole preventive therapy C.4. HIV/AIDS care and support C.5. Antiretroviral therapy to TB patients.

13. Intensified TB case finding Screening for TB symptoms and signs Screening tool should be developed nationally referring to the NTP guidelines Advantages: interrupts TB transmission by infectious cases prevents mortality including PLHIV on ART decreases risk of nosocomial TB transmission offers the opportunity to provide TB preventive therapy keeps XDR TB at the bay Previously undiagnosed active TB was detected in up to 11% of PLHIV Can be introduced with little additional cost

14. Isoniazid preventive therapy (IPT) Given to individuals with latent infection with Mycobacterium tuberculosis Prevents active TB in 40-60% of the patients. Difficulties identification of HIV-positive subjects screening to exclude active TB treatment adherence Individual than public health measure Botswana run nationwide programme whilst Rwanda excludes it from its TB/HIV package Evidence on combined use of IPT and ART

15. IPT and ART Treatment TB incidence No IPT � No ART 3.6/100 PY No IPT- Only ART 1.7/100 PY Only IPT-No ART 0.7/100 PY IPT and ART 0.6/100 PY (Trio Study Group. Abstract 16th AIDS Conference, Toronto, August 2006)

16. TB infection control in HIV services Administrative measures early diagnosis and treatment Separation of PTB suspect Environmental measures maximise natural ventilation UV radiation Personal measures protection of PLHIV and HCW IPT

17. Further important actions Implement new smear negative TB guidelines Different approach for HIV and non-HIV settings Immediate MDR and XDR surveillance Generic guideline is available for use Joint TB DR and HIV surveys (e.g. using sputum) Strengthen Management of MDR-TB & XDR-TB Initiate referral sites for MDR-TB Use the Green Light Committee mechanism for 2nd line drugs Strengthen laboratory capacity Culture for drug susceptibility testing and diagnosis Expand national reference labs Support supranational labs (donors and multilateral) Simple, rapid and new tools Resource mobilisation-Donors and governments

18. Conclusion XDR TB is yet another call for effective collaboration between the TB and HIV control programs to deliver collaborative TB/HIV activities. XDR TB carries huge risks for functioning ART programs

19. Conclusion " To fight AIDS we must do more to fight TB"