1. TUBERCULOSIS, TB/HIV & MDR-TB
The Perfect Storm:
TUBERCULOSIS, TB/HIV & MDR-TB
Dr Mario Raviglione
Director, Stop TB Department
WHO
Geneva
Reversing the Tide: the End of Tuberculosis
Columbia University, New York, March 2006

2. TB control crucial within development agendas
Why talk of TB?
TB control crucial within development agendas
disease of poverty
– by definition
TB control is:
a human right,
a public good,
an MDG quick-win
ignorance is a killer

3. The burden of TB in 2006 1.7 million deaths in 2004
– 98% of these in developing world
250,000 deaths due to TB/HIV
MDR-TB present in 102 of 109 countries
8.9 million new cases in 2004 – 80% in 22 high-burden countries

4. Highest incidence rates per capita in Africa…
= 300 or more
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5. …but 2/3 of global cases in Asia
= 1 million or more

6. Impact of HIV on TB and of TB in PLWHA
Direct:
Reactivation of TB infection acquired before HIV infection (from 10% lifetime to 3-13%/year)
Rapid progression of TB infection acquired after HIV infection (often a matter of weeks, not months/years)
Rapid progression of HIV disease (result of a more immunocompromised status)
TB leading cause of HIV-related deaths in the world
Indirect:
TB transmission to the rest of the population, regardless of the HIV status

7. TB and TB/HIV in Africa The facts:
2.35m estimated cases per year in Sub Saharan Africa
About 50% of them detected
29% of global total, yet only
11% or world's population
½m TB deaths annually, half
of them associated with HIV
TB notification rates falling
in HIV uninfected people while high in HIV infected

8. MDR-TB prevalence in new cases, 1994-2003
14.2
Kazakhstan
14.2
Israel
13.7
Russia (Tomsk)
13.2
Uzbekistan
7.8
12.2
Estonia
10.4
China (Liaoning)
9.4
Lithuania
9.3
Latvia
9.0
Russia (Ivanovo)
7.8
China (Henan)
6.6
Dominican Rep
5.3
Ivory Coast
5.0
Iran
4.9
Ecuador

9. Economic impact of TB ALSO:
Provision of diagnostic and treatment services:
US$ 4.7 billion per year on average required as outlined in the Global Plan
Productivity losses due to mortality:
1.7 million deaths per year, mainly economically productive adults
Macro-economic level:
recent study suggests 10% increase in TB incidence cuts economic growth by 0.2% - 0.4% per year
Sources: Croft et al, 1998; Needham et al, 1998; Wyss et al, 2001; Rajeshwari et al, 1999; Floyd et al, 2003; Nganda et al, 2003; Wandwalo et al, 2005; Okello et al, 2003; Floyd et al, 1997; Khan et al, 2002

10. Cost per DALY gained in Asia and Africa
Investment in TB control is
highly-cost effective
Intervention
Cost per DALY gained in Asia and Africa
Disease Control Priorities Project (year 2001 US$)
BMJ series on MDGs
(year 2000 US$)
Treatment of new smear-positive cases, DOTS
5-33 2
Treatment of new smear-negative/ extrapulmonary cases, DOTS
63-116
~10-20
Treatment of MDR-TB
75-130
~30-50
ART for HIV+ people, including those with TB ~
In 2 regions with vast majority of global cases, main TB control interventions cost around or less than US$100 per year of life saved
BMJ series on MDGs for health, rated all TB control interventions "highly cost-effective" (cost to gain 1 DALY less than GDP per capita)
Sources: Dye and Floyd, 2006; Baltussen et al, BMJ 2005; Evans et al, 2005

11. Global TB control targets
Stop TB Partnership – 2015:
50% reduction in TB prevalence and deaths by 2015
Millennium Development Goals – 2015, Goal 6: Combat HIV/AIDS, malaria and other diseases
Target 8: to have halted by 2015 and begun to reverse
the incidence of malaria and other major diseases
Indicator 23: prevalence and deaths associated with TB
Indicator 24: proportion of TB cases detected
and cured under DOTS
World Health Assembly :
- To detect at least 70% of infectious TB cases
- To treat successfully at least 85% of detected cases

12. DOTS treatment success close to target
for 1.7m smear (+) patients in 2003
WHA Target 85%
Treatment success (%)

13. More than 22 million patients treated through DOTS in 10 years… and accelerating!80
WHA target 70% 70 60
accelerated progress:
target 2005 50
Case detection rate, smear-positive cases (%) 40
DOTS begins 30
average rate of progress 20 10
1990
1995
2000
2005
2010
2015
Year

14. Trends in global TB prevalence and deaths
290 32
280 31
270 30
260 29
TB prevalence rate
(all forms)/100k
TB death rate/100k/yr
250 28
240 27
230 26
220 25
2000
2001
2002
2003
2004

15. Global TB incidence is rising Estimated TB incidence/100K/yr
Global incidence is rising at 1%
Global TB incidence is rising
1% per year
Africa - high HIV
400
300
Africa - low HIV
200
Estimated TB incidence/100K/yr
World
E Europe
100
World
exc Afr EEur
1990
1995
2000
2005

16. WHO recommended Stop TB Strategy
to reach the 2015 MDGs

17. G8 leaders commit to TB control in final communiqué
Commitment to fight TB and TB/HIV in Africa
May 2005
World Health Assembly resolution on sustainable financing for TB control
July 2005
G8 leaders commit to TB control in final communiqué
August 2005
46 Ministers of Health in Africa declare TB an emergency across the Region
October 2005
African Union Ministers of Health support the TB emergency declaration in Africa

18. The Global Plan to Stop TB 2006-2015: Actions for Life
"If 2005 was the year of commitment, then 2006 must be the year of delivery"
Gordon Brown UK Finance Minister
"We're willing to triple our funding for tuberculosis, and we urge others to do the same" Bill Gates, Microsoft founder
"…call upon African governments to commit their share of the resources needed…" Olusegun Obasanjo, Nigerian President

19. Structure of the Global Plan to Stop TB 2006-2015 Part I
"If 2005 was the year of commitment, then 2006 must be the year of delivery"
Gordon Brown UK Finance Minister
Part I
General strategic directions
Part II
Regional scenarios
Part III
Specific actions/plans by area of work and secretariat
"We're willing to triple our funding for tuberculosis, and we urge others to do the same" Bill Gates, Microsoft founder
"…call upon African governments to commit their share of the resources needed…" Olusegun Obasanjo, Nigerian President

20. Global Plan to Stop TB 2006-2015 Total funding needs:
available funding and funding gap
by area of work

21. Global Plan key messages
Funding the Global Plan will:
treat 50 million TB patients
save 14 million extra lives
The ultimate goal of TB - elimination by
depends on continued innovation in vaccines, drugs and diagnostics
Achievable and possible - under the
$56 billion action plan for 10 years

22. A "perfect storm" but still off the radar?
Combat HIV/AIDS, malaria and 'other diseases'
African Minister of Health: "I thought TB
was only a side effect of HIV/AIDS"
Increase in annual international funding, : $5 billion for HIV/AIDS vs just $300 million for TB
Only 15% of $9.5 billion to TB in first 5 rounds
For Africa: Multicountry AIDS Programme, Malaria Booster Programme and just 3 TB projects
PepFAR: minimum financing for TB/HIV

23. Sign now - THE CALL TO STOP TB