1. HIV and Tuberculosis interaction and integration Anthony D Harries The “Union”, Paris, France London School of Hygiene & Tropical Medicine, UK

2. Epidemiology and Effects of HIV-TB Interaction

3. Risk of TB in persons with Mycobacterium tuberculosis Not HIV Infected Life time risk = 5-15% HIV Infected Annual risk = 5-15%

4. Tuberculosis incidence rates (cases / 100 person-years) in HIV-infected patients prior to availability of antiretroviral therapy in South Africa and Italy Lawn et al, 2010: data adapted from Badri et al., 2002 and Antonucci et al., 1995

6. HIV increases the number of young women with TB

7. Estimated HIV-prevalence in patients with TB WHO Global Tuberculosis Control 2011

8. Advancing HIV immune suppression [less inflammation and granuloma formation] PTB Smear-positive Cavities Upper lobe disease PTB Smear-negative Infiltrations Lower lobe disease EPTB Disseminated disease

9. Mortality rates in HIV-infected smear- positive PTB patients before era of ART CountryCD4 count in HIV-positive patientsHIV-negative patients <200200-499500 or > Cote d’Ivoire: at 6 months 1 10%4%3%~1% Zaire: at 24 months 2 67%22%8%< 2% 1 Ackah et al, Lancet 1995; 345: 607-10; 2 Perriens et al, N Engl J Med 1995; 332: 779 – 84

10. Tugela Ferry, SAMDR-TBXDR-TB Number272382 HIV-infected %90%98% 1-month mortality40%51% 1-year mortality71%83% Gandhi et al, Am J Respir Crit Care Med 2010, 181: 80-6 Lethal combination of HIV and DR-TB

11. High rate of recurrent TB after successful treatment HIV+veHIV-ve Zaire18%6% (Perriens et al, 1991) Kenya17% 0.5% (Hawken et al, 1993) Zambia22%6% (Elliott et al, 1995) S.Africa16%6% (Sonnenberg et al, 2001)

12. Number of people receiving antiretroviral therapy in low- and middle-income countries, by region, 2002 – 2010

13. Of HIV-infected patients who start antiretroviral therapy (ART) in Africa 8% - 26% die in first year Often due to diagnosed and undiagnosed TB Lawn SD et al. AIDS 2008; 22: 1897 - 1908

14. TB Control derailed: More patients More difficult diagnosis Higher mortality Higher rate of recurrence HIV/AIDS care affected: Increased morbidity Increased mortality HIV effects on TB TB effects on HIV

15. How to decrease the joint burden of HIV and TB?

16. WHO Interim Policy: Jan 2004 Milestone Clear guidance based on incomplete evidence Only 14 pages Multiple languages Adopted in > 160 countries and saved ~1 million lives in 8 years

17. Between 2004 and 2012, new evidence for TB prevention role of ART Expanded use of HIV testing for patients with suspected TB, family members or contacts Better integration of HIV-TB care

18. 2012

19. C. Reduce HIV burden in patients with TB Provider initiated HIV testing and counselling [PITC] If HIV- seropositive Start cotrimoxazole preventive therapy as soon as possible Start antiretroviral therapy as soon as possible

20. B. Reduce TB burden in PLHIV Active TBNo active TB Anti-TB Treatment Isoniazid Preventive Therapy Infection control (TB) in high risk settings Intensified case finding for TB Early antiretroviral therapy

21. A. Integrated services: TB Clinic ART Clinic Number TB cases registered 340 Number TB cases HIV tested 275 Number TB cases HIV-positive 192 Number HIV+TB cases on CPT 186 Number HIV+TB cases on ART 122 Number of patients on ART 1025 No. screened for TB at last visit 825 No. diagnosed with TB 8 No. started on IPT 72 Co-location or integration of clinics TBHIV and HIVTB Monitoring

22. Are we making progress? HIV-TB Collaborative ActivityResults for 2010 % HIV-infected persons in care actively screened for TB (ICF)58 % HIV-infected persons in care and eligible and started on IPT25 % TB patients tested for HIV34 % HIV-positive TB patients started on CPT79 % HIV-positive TB patients started on ART46 WHO Report 2011 Global Tuberculosis Control

23. WE NEED TO DO BETTER: Funding: we have to meet the funding gap Knowledge: we need to continue doing the relevant science Implementation: we need to do what works and be accountable