1. WHO/AFRO Vision for TB/HIV Control.
Presented at the 3rd Global TB/HIV Working Group Meeting. 4-6 June, 2003.
By Dr Wilfred Nkhoma

2. Outline of presentation
Magnitude of TB burden (including impact of dual TB/HIV infection)
Performance with relation to targets
AFRO’s Vision for combating TB/HIV
What has been happening so far ?
Where do we go from here ?

3. Total Reported Tuberculosis Cases, AFRO, 2000
Source: WHO/AFRO TB Program as of December 2001

4. Magnitude of the TB problem (1):
Highest TB rates per capita are in Africa
25 to 49
50 to 99
100 to 299
< 10
10 to 24
300 or more
No Estimate
per 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 2002

5. Adults and children Living with HIV/AIDS. Estimates at the end of 2002
Continental Europe
Oriental Europe &
Central Asia
North America
1,2 million
Eastern & Pacific Asia
1,2 million
North Africa & Maghreb region
Caribbean
South & South East
Asia
6 millions
Latin America
Sub-Saharan African
Australia & New Zealand
1,5million
29,4 millions
15 000
Total : 42 millions

6. S

7. HIV - MTB co-infection, 1999 co infected people (thousands) < 0.1
0.1 to 0.9
1 to 9
10 to 99
100 to 299
300 or more
no estimate

8. In 1983, only one country, Tanzania was implementing what later became known as the DOTS Strategy. The number increased slowly at first until the early ninenties when TB control began to receive increased attention culminating in 1993 by the declaration of the the global emergency by WHO. Since then more and more countries have adopted the strategy and the rise was particularly exponential between 1994 and The number has remained static for two consecutive years since then, and little further movement is expected in the short term. For all intents and purposes, adoption of the strategy could be considered a prerequisite to effective TB Control. This trend in coverage is therefore a significant development for purposes of meeting global and regional targets for TB Control.

9. REPORTED DOTS COVERAGE BY COUNTRY. AFRO 2001

10. Case detection rates by WHO region 2001 100 80 60 40 20 AFR AMR EMR
DOTS detection rate 60
Case detection (%) 40 20
AFR
AMR
EMR
EUR
SEAR
WHO region

11. Treatment success rate by WHO Region : DOTS 1998
100 90 80 70
Not
evaluated 60
Percent of cohort
Not treated 50
successfully 40 30
Treated
successfully 20 10
AFR
AMR
EMR
EUR
SEAR
WPR

12. Compared to other WHO Regions, the picture is one of the most improved region between 1996 and 1998 cohorts, rivaled only by WPR and EUR. SEAR and EMR though higher than AFR, have witnessed a decline towards AFR levels.

13. TRENDS OF NEW HIV INFECTIONS IN AFRICA
THE YEAR 2000 WAS THE FIRST TIME AFRICA SAW A DECREASE IN NEW INFECTIONS
THE 3.8 MILLION NEW INFECTIONS IN 2000 WERE ACTUALLY LOWER THAN THE 4 MILLION NEW INFECTIONS OF 1999
3.4 NEW INFECTIONS IN 2001
WHY THE DROP ?
EPIDEMIC HAS GONE ON FOR SO LONG THAT MOST PEOPLE AT RISK HAVE ALREADY BEEN INFECTED ?
INTERVENTION PROGRAMMES BEGINNING TO PAY OFF ?

14. HIV Prevalence at Selected ANC Sentinel Sites UGANDA
Source: HIV/AIDS Surveillance Report, June 2001, MoH

15. HIV prevalence rate among pregnant
15 to 19-year-olds, Lusaka, Zambia, 1993 to 1998 35 30 25
1993
HIV prevalence (%) 20
1994
1998 15 10 5
Chelstone
Chilenje
Kalingalinga
Matero
Clinic
Source: Ministry of Health, Zambia, 1999

16. Median HIV Prevalence in ANC Attendees - Senegal
Source: MoH, US Census Beureau

17. Estimated access to care interventions for HIV/AIDS in Africa South of the Sahara. 2001
6% access to VCT services
23% access to essential HIV/AIDS care package
6% coverage with Cotrimoxazole in adults and 1% in children
Only 300,000 of 6 million people on ARVs are in developing countries
Only 1% (50,000 of 4 million) of those in need of ARVs in developing countries have access to them.
1% coverage with PMTCT services

18. AFRO’s Vision for TB/HIV Control (1)
Efficient delivery of core effective TB and HIV/AIDS prevention, care and support services:
Universal application of DOTS strategy for TB and minimum package of services for HIV/AIDS

19. PRIORITY HIV/AIDS INTERVENTIONS (1)
Prevention
- Voluntary counselling & testing
- Promotion of protective behaviours
- Prevention & treatment of STIs
- Adolescent health & development
- Blood safety, bio-safety
- Prevention of Mother-to-child transmission

20. PRIORITY HIV/AIDS INTERVENTIONS (2)
Care & Support (within a continuum…)
- Treatment of opportunistic infections,
palliative care
- Access to anti-retroviral drugs
- Community-based care
- VCT
- TB/HIV programme & service links

21. PRIORITY HIV/AISDS INTERVENTIONS (3)
Selection of essential package for different levels & service providers
Based on community-defined needs & priorities, capacities, resources, opportunities
Integrated into health service package

22. AFRO’s Vision for TB/HIV Control (2)
Collaboration between TB & HIV/AIDS
Control Programs aimed at:
increased access to TB & HIV/AIDS prevention, care and support services as part of a continuum
Reducing the incidence of HIV related tuberculosis
Reducing morbidity and mortality due to TB and other Ois among PLWHA

23. Some key collaboration interventions between TB & HIV/AIDS/STD Control Programs
Development of supportive policy environment
Access to HIV VCT by TB patients
Access to TB services for PLWHAs: Screening, diagnosis and treatment [expansion of DOTS],
INH prophylaxis
Prophylaxis for Ois: e.g Co-trimoxazole prophylaxis for PLWHA and TB patients
Access to ARVs by HIV-positive TB patients
Advocacy and community mobilisation for TB/HIV/AIDS/STD control

24. What has been happening so far ?
Policy Environment:
Regional TB/HIV Strategy: Final draft
Regional Guidelines for Implementation of Collaborative TB/HIV activities: First draft at peer review stage
Regional Guidance Kit for HIV/AIDS/STI & TB Community and Home based Care: Final draft
Regional Clinical Guidelines for HIV/AIDS Care. Final draft stage
Regional VCT Guidelines. Final draft stage

25. What has been happening so far ?(2)
Implementation of TB/HIV activities in Member States:
ProTEST & expansion since 1998: Malawi, Zambia, South Africa
New Implementation plans:
February 2002: Ethiopia, Kenya, Mozambique, Tanzania, Uganda
May 2003: Burkina Faso, Chad, Cote D’ Ivoire, DRC, Senegal, Rwanda

26. What has been happening so far (3)
GFATM FUNDING FOR TB/HIV:
Round 1: Ethiopia, RSA, Rwanda & Zambia
Round 2 (Cat 3): Lesotho, Sao Tome & P, Tanzania, Togo
GFATM FUNDING FOR TB:
Round 1: Ghana.
Round 2:
Cat 2: (12 countries):Benin, Chad, DRC, Kenya, Lesotho, Liberia, Mauritania, Mozambique, Namibia, Nigeria, Sierra Leone, Uganda
Cat 3 (17 countries): Botswana, Burkina Faso, Burundi, Cameroon, CAR, Cote D ‘ I voire, Equatorial Guinea, Eritrea, Guinea, Lesotho, Rwanda, Sao Tome & P, Senegal, Swaziland, Tanzania, Togo, Zimbabwe

27. What has been happening so far (4)
GFATM FUNDING FOR HIV/AIDS
Round 1: 11 countries [Burundi, Ghana, Kenya, Malawi, Nigeria, Senegal, South Africa, Tanzania, Uganda, Zambia, Zimbabwe]
Round 2:
Cat 1: Madagascar & Swaziland
Cat 2: 15 countries [Benin, Botswana, Burkina Faso, CAR, Cote d’Ivoire, Ethiopia, Guinea, Kenya, Lesotho, Liberia, Mozambique, Namibia, Togo, Zanzibar]
Cat 3: 13 countries [Cameroon, Chad, Comoros, DRC, Equatorial Guinea, Eritrea, Mauritania, Mauritius, Nigeria, Rwanda, Seychelles, Sierra Leone, South Africa

28. Developing a strong policy environment and health infrastructure
SOME CHALLENGES TO EFFECTIVE TB/HIV/AIDS CONTROL IN THE CONTEXT OF NATIONAL PROGRAMMES
Developing a strong policy environment and health infrastructure
How to scale up coverage with effective interventions (TB & HIV/AIDS)
Ensuring adequate resources (human, drugs, logistics and other)
How to unify efforts to cater for common clients (TB & HIV/AIDS suspects and patients)
Positioning to take advantage of new opportunities

29. Opportunities for scaling up
Health sector reforms in countries
GDF for TB. Could use similar approach for ARVs?
World Bank MAP Projects
GFATM funding
Bilateral funding initiatives
US President’s pledge for HIV/AIDS support
New drug development initiatives

30. Where do we go from here ?
In the light of the magnitude of the TB/HIV problem in Africa, the prevailing socio-political landscape and the responses to-date, what should African countries be doing to achieve TB control in the face of the HIV/AIDS epidemic ?