1. Guidelines for HIV surveillance among TB patients
TB/HIV Surveillance Workshop
22-24 September, 2004, Addis Ababa, Ethiopia
WHO/HTM/TB/
WHO/HIV/
UNAIDS/04.30E
Guidelines for HIV surveillance among TB patients
Second edition
(field version)
Slide n 1:
Second edition of the guidelines for HIV surveillance among TB patients has been recently completed. First edition was done in 1994.
GLOBAL PARTNERSHIP TO STOP TB

2. Methodology for revision of guidelines
Slide n 2:
Writing committee mostly represents two Global working groups: one is the TB/HIV global group. Second is the Working group on Global HIV/AIDS/STI surveillance.
The series of discussion between two working group on the guidelines have been done. All comments are incorporated copies of guidelines will be widely disseminated in the next weeks.

3. Background
HIV pandemic has continued to impact upon global tuberculosis situation
1994 WHO guidelines - one specific approach
Increasing availability of routine HIV testing and counselling
ART scaling-up: "3 by 5" initiative and President's
Emergency Plan for AIDS Relief
Slide n 3:
As the first guidelines edition was focused on only one surveillance method and the global TB/HIV situation has been changed since the first guidelines development (ongoing spread of HIV with strong impact on TB situation, increase of HIV T&C availability, 3by5) the upgraded version of guidelines has been in demand.

4. Guidelines objective
To provide a framework for the methods to be used for measuring HIV prevalence among tuberculosis patients and to encourage the implementation of HIV surveillance.

5. Rationale for surveillance
Better understanding of the impact
Increasing awareness
Targeting of resources and planning
Monitoring and evaluation
Provision of ART to TB patients
Slide n 3:
As the first guidelines edition was focused on only one surveillance method and the global TB/HIV situation has been changed since the first guidelines development (ongoing spread of HIV with strong impact on TB situation, increase of HIV T&C availability, 3by5) the upgraded version of guidelines has been in demand.

6. Challenges to surveillance
Ethical
Organisational and financial
Slide n 5:
Strong TB/HIV surveillance system facilitates a better understanding of the epidemiological interaction of TB and HIV. Since then TB/HIV collaborative activities can be better harmoniesed in order to strengthen the planning, fundraising, A&C and monitoring and evaluation.

7. Different surveillance methods
Data from routine HIV testing of tuberculosis patients
Sentinel methods
Periodic (special) surveys
Slide n 6:
The main challenges related to HIV surveillance activities are ethical, organizational and financial. Ethical challenge is especially in the context of UAT. Organizational one is related to the lack of political commitment leading to the lack of recourses. The other important organizational problem is the lack of well trained epidemiologists.

8. Selection of surveillance method
Criteria
Recommended HIV surveillance methods
Generalized HIV epidemic state
Data from routine HIV testing of TB patients and Periodic (special) or sentinel surveys
Concentrated HIV epidemic state
Data from routine HIV testing of TB patients or Periodic (special) or sentinel surveys
Low-level HIV epidemic state
Periodic (special) or sentinel surveys
Slide n 7:
The main methods to be used for HIV surveillance among TB patients proposed in the guidelines are….

9. Surveillance methods for use in different HIV and tuberculosis prevalence settings (1)
3. Data from routine HIV testing of tuberculosis patients
Can form the basis of a reliable surveillance system
Slide n 10:
Sentinel surveys are useful for:
Useful for monitoring trends and can identify, at an early stage, areas where routine HIV counselling and testing of individuals with tuberculosis should be undertaken
In countries with low or concentrated HIV epidemic states where HIV testing is not yet routinely offered to all TB patients
May also be useful in calibrating results from other surveillance methods – to help identify possible bias

10. Surveillance methods for use in different HIV and tuberculosis prevalence settings (2)
2. Sentinel surveys
To monitor trends
Slide n 9:
Periodic (special) surveys should be undertaken in:
In settings where no previous surveillance has been undertaken
Tailored surveys may be undertaken in countries, where HIV prevalence is in at least one defined subpopulation (IDUs, SW, MSM) >5% , but where routine HIV counselling and testing of all TB patients is not yet in place
Repeated at 2-3 years intervals in countries with a low-level HIV epidemic (HIV prevalence has not consistently exceeded 5% in any defined subpopulation)
May also be useful in calibrating results from other surveillance methods – to help identify possible bias

11. Surveillance methods for use in different HIV and tuberculosis prevalence settings (3)
Periodic (special) surveys
In settings where no previous surveillance has been undertaken
Repeated surveys at 2-3 years intervals
Slide n 8:
WHO propose to select the methods for the surveillance system according to the country HIV epidemic state…….
Yet, we would like to emphasize the importance of the universal HIV testing offer for all TB patients as a basis of the reliable surveillance system.

12. Difficult methodological issues
Ethical debate surrounding
unlinked anonymous HIV testing
2. Use of sputum samples in HIV surveillance
Slide n 11:
Data from routine testing of TB patients -when available- should be used for surveillance purpose.

13. Concluding remarks
HIV surveillance among tuberculosis patients is a key TB/HIV activity
Surveillance methods in countries should vary according to the underlying HIV epidemic state
Consideration of the ethical issues and any possible organisational constraints is important
The guidelines to be piloted in 7 sites
Slide n 12:
Methodological difficulties are related to:
ethical questions as this complex issues and new version of the WHO guidelines are very welcome
use of sputum samples in HIV surveillance
Benefits of using sputum samples in surveillance of tuberculosis patients
Lack of robust evidence for HIV testing of sputum samples across all HIV prevalence settings

14. Acknowledgments Writing Committee: Kevin De Cock
Jesus M. Garcia Calleja
Peter Ghys
Catherine Hankins
George Loth
Jai Narain
Wilfred Nkhoma
Paul Nunn
Rick O’Brien
Jeroen Van Gorkom
Pieter Van Maaren
Brian Williams

15. Thank You!