Managing TB in the era of HIV Weathering the storm: Managing TB in the era of HIV Brian Williams, Paul Nunn and Chris Dye

DOTS don’t do it! —Kevin De Cock

DOTS don’t do it! What does do it? —Kevin De Cock DOTS plus... TB preventive therapy? TB mass treatment (mines)? ART (Brazil)? Targetted ART? Behaviour change (Uganda)?

Where do we need to concentrate our efforts? What is the nature of the TB-HIV problem in different parts of the world? Where do we need to concentrate our efforts? —Gijs Elzinger

HIV prevalence (%): low risk groups, capital/major city 0 to 0.1 0.1 to 1 1 to 5 5 to 10 10 to 20 20 to 40 HIV prevalence (%): low risk groups, capital/major city

25 11 8 24 16 5 10 Kyela 0.5 Bukoba 7 Kisesa Mwanza Kigoma Arusha Kilimanjaro Lindi Dodoma Lake Tanganyika Tabora Tanga Pemba Zanzibar DAR ES SALAAM Iringa Mbeya Lake Nyasa Mtwara Estimated prevalence of infection (%) among women attending ante-natal clinics in Tanzania in 1994.

Estimated TB Incidence Rates, 2000 25 to 49 50 to 99 100 to 299 < 10 10 to 24 300 or more No Estimate per 100 000 population The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2001

Above the red line the prevalence of infection is increasing, below the red line it is decreasing

Annual rate of change of TB incidence (%) -5 to -2 -2 to 0 0 to 2 2 to 5 5 to 10 > 10 < -5

Estimated HIV-infected TB cases per 100k in 2000.

Proportion of TB cases attributable to HIV in 2000.

ANC data Possible courses for the HIV epidemic in India

Incidence of SS+ tuberculosis per 100,000 people for each of three HIV epidemics and two levels of TB control. Green without HIV; red with HIV

Countries ranked by a) Number: the number of TB cases attributable to HIV (thousands) and b) Rate: the number of TB cases attributable to HIV per 100,000 population. Above red line: 80% of total number; above blue line: 90% of total number Rank Country Number Country Rate Rank Country Number Country Rate 1 S. Africa 77.8 Botswana 724 16 Rwanda 7.6 C. d'Ivoire 197 2 Ethiopia 59.2 Zimbabwe 501 17 B. Faso 6.5 Uganda 173 3 Nigeria 49.9 Lesotho 492 18 Burundi 6.4 Tanzania 155 4 Kenya 43.9 Swaziland 478 19 Ghana 6.0 Cameroon 147 5 India 41.4 Zambia 409 20 Thailand 5.6 B. Faso 132 6 Zimbabwe 29.2 Namibia 385 21 Botswana 5.5 Congo 128 7 Tanzania 25.2 S. Africa 333 22 CAR 4.9 Cambodia 126 8 DR Congo 22.6 Djibouti 325 23 Myanmar 4.9 Togo 113 9 Mozam. 21.5 Malawi 323 24 Lesotho 4.8 DR Congo 105 10 Zambia 18.9 Kenya 295 25 Haiti 3.7 Nigeria 96 11 Uganda 17.3 CAR 290 26 Angola 3.1 Haiti 94 12 Malawi 16.1 Mozam. 258 27 Namibia 3.1 Gabon 82 13 C. d'Ivoire 15.0 Burundi 228 28 China 2.9 Ghana 64 14 Cameroon 10.1 Rwanda 211 29 Togo 2.4 S. Leone 56 15 Cambodia 7.7 Ethiopia 209 30 USA 2.3 Angola 56

Countries ranked by a) Number: the number of TB cases attributable to HIV (thousands) and b) Rate: the number of TB cases per 100,000 population. Gross national income: red < $500 p.a.; blue $500 to $1000; black > $1000 p.a. Above red line: 80% of total number; above blue line: 90% of total number Rank Country Number Country Rate Rank Country Number Country Rate 1 S. Africa 77.8 Botswana 724 16 Rwanda 7.6 C. d'Ivoire 197 2 Ethiopia 59.2 Zimbabwe 501 17 B. Faso 6.5 Uganda 173 3 Nigeria 49.9 Lesotho 492 18 Burundi 6.4 Tanzania 155 4 Kenya 43.9 Swaziland 478 19 Ghana 6.0 Cameroon 147 5 India 41.4 Zambia 409 20 Thailand 5.6 B. Faso 132 6 Zimbabwe 29.2 Namibia 385 21 Botswana 5.5 Congo 128 7 Tanzania 25.2 S. Africa 333 22 CAR 4.9 Cambodia 126 8 DR Congo 22.6 Djibouti 325 23 Myanmar 4.9 Togo 113 9 Mozam. 21.5 Malawi 323 24 Lesotho 4.8 DR Congo 105 10 Zambia 18.9 Kenya 295 25 Haiti 3.7 Nigeria 96 11 Uganda 17.3 CAR 290 26 Angola 3.1 Haiti 94 12 Malawi 16.1 Mozam. 258 27 Namibia 3.1 Gabon 82 13 C. d'Ivoire 15.0 Burundi 228 28 China 2.9 Ghana 64 14 Cameroon 10.1 Rwanda 211 29 Togo 2.4 S. Leone 56 15 Cambodia 7.7 Ethiopia 209 30 USA 2.3 Angola 56

Countries ranked by a) Number: the number of TB cases attributable to HIV (thousands) and b) Rate: the number of TB cases per 100,000 population. Gross national income: red < $500 p.a.; blue $500 to $1000; black > $1000 p.a. Above red line: 80% of total number; above blue line: 90% of total number Rank Country Number Country Rate Rank Country Number Country Rate 1 S. Africa 77.8 Botswana 724 16 Rwanda 7.6 C. d'Ivoire 197 2 Ethiopia 59.2 Zimbabwe 501 17 B. Faso 6.5 Uganda 173 3 Nigeria 49.9 Lesotho 492 18 Burundi 6.4 Tanzania 155 4 Kenya 43.9 Swaziland 478 19 Ghana 6.0 Cameroon 147 5 India 41.4 Zambia 409 20 Thailand 5.6 B. Faso 132 6 Zimbabwe 29.2 Namibia 385 21 Botswana 5.5 Congo 128 7 Tanzania 25.2 S. Africa 333 22 CAR 4.9 Cambodia 126 8 DR Congo 22.6 Djibouti 325 23 Myanmar 4.9 Togo 113 9 Mozam. 21.5 Malawi 323 24 Lesotho 4.8 DR Congo 105 10 Zambia 18.9 Kenya 295 25 Haiti 3.7 Nigeria 96 11 Uganda 17.3 CAR 290 26 Angola 3.1 Haiti 94 12 Malawi 16.1 Mozam. 258 27 Namibia 3.1 Gabon 82 13 C. d'Ivoire 15.0 Burundi 228 28 China 2.9 Ghana 64 14 Cameroon 10.1 Rwanda 211 29 Togo 2.4 S. Leone 56 15 Cambodia 7.7 Ethiopia 209 30 USA 2.3 Angola 56

What will do it? 1. Everywhere: strengthen and extend case finding and successful treatment (DOTS). 2. High burden countries: develop additional interventions. 3. Southern and East Africa: massive inputs to avoid disaster. 4. Parts of Central and West Africa, Cambodia, Thailand, Myanmar, and Haiti: additional efforts to contain HIV. 3. India and China: Monitor the HIV epidemic very closely. 4. Former Soviet Union: Targeted interventions among high-risk groups. 5. Learn from Thailand, Cambodia, Uganda, Brazil, Senegal.

We cannot allow the AIDS epidemic to ruin the realization of our dreams. Existing statistics indicate that we are at the beginning of the AIDS epidemic in our country. Unattended, however, this will result in untold damage and suffering by the end of the century. Chris Hani (1990) Maputo AIDS conference

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

The proportion of people with HIV that live in each region of the world

Tuberculosis death rate in 1,000s for each of three HIV epidemics and two levels of TB control. Green without HIV; red HIV+ TB deaths; blue HIV- TB deaths

South Africa – TB Incidence This shows the TB incidence in South Africa for the worst case scenario that HIV prevalence increases to 30%, 1.5 times its current value. The next slide shows the effectiveness of different interventions in reducing TB over 10 years.

Estimated numbers of TB cases by country in 2000

Annual rate of change of TB incidence (%) < -5 -5 to -2 -2 to 0 0 to 2 2 to 5 > 5 Annual rate of change of TB incidence (%)

Prevalence of HIV in adults (15 to 49) 0 0.1 0.2 0.3 0.0 0.1 0.2 0.3 0.8 0.6 0.4 0.2 0.0 Prevalence of HIV in TB cases Measurements made on the same population

0.00  0.01 0.01  0.05 0.05  0.10 0.10  0.50 0.50  2.00 2.00  4.00 Prevalence of HIV (%)