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

2. DOTS don’t do it!
—Kevin De Cock

3. 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)?

4. 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

5. 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

6. 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.

7. Estimated TB Incidence Rates, 2000
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 2001

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

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

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

11. Proportion of TB cases attributable to HIV in 2000.

12. ANC data
Possible courses for the HIV epidemic in India

13. 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

14. 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 Rwanda 7.6 C. d'Ivoire 197
2 Ethiopia 59.2 Zimbabwe B. Faso 6.5 Uganda 173
3 Nigeria 49.9 Lesotho Burundi 6.4 Tanzania 155
4 Kenya 43.9 Swaziland Ghana 6.0 Cameroon 147
5 India 41.4 Zambia Thailand 5.6 B. Faso 132
6 Zimbabwe 29.2 Namibia Botswana 5.5 Congo 128
7 Tanzania 25.2 S. Africa CAR 4.9 Cambodia 126
8 DR Congo 22.6 Djibouti Myanmar 4.9 Togo 113
9 Mozam Malawi Lesotho 4.8 DR Congo 105
10 Zambia 18.9 Kenya Haiti 3.7 Nigeria 96
11 Uganda 17.3 CAR Angola 3.1 Haiti 94
12 Malawi 16.1 Mozam Namibia 3.1 Gabon 82
13 C. d'Ivoire 15.0 Burundi China 2.9 Ghana 64
14 Cameroon 10.1 Rwanda Togo 2.4 S. Leone 56
15 Cambodia 7.7 Ethiopia USA 2.3 Angola 56

15. 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 Rwanda 7.6 C. d'Ivoire 197
2 Ethiopia 59.2 Zimbabwe B. Faso 6.5 Uganda 173
3 Nigeria 49.9 Lesotho Burundi 6.4 Tanzania 155
4 Kenya 43.9 Swaziland Ghana 6.0 Cameroon 147
5 India 41.4 Zambia Thailand 5.6 B. Faso 132
6 Zimbabwe 29.2 Namibia Botswana 5.5 Congo 128
7 Tanzania 25.2 S. Africa CAR 4.9 Cambodia 126
8 DR Congo 22.6 Djibouti Myanmar 4.9 Togo 113
9 Mozam Malawi Lesotho 4.8 DR Congo 105
10 Zambia 18.9 Kenya Haiti 3.7 Nigeria 96
11 Uganda 17.3 CAR Angola 3.1 Haiti 94
12 Malawi 16.1 Mozam Namibia 3.1 Gabon 82
13 C. d'Ivoire 15.0 Burundi China 2.9 Ghana 64
14 Cameroon 10.1 Rwanda Togo 2.4 S. Leone 56
15 Cambodia 7.7 Ethiopia USA 2.3 Angola 56

16. 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 Rwanda 7.6 C. d'Ivoire 197
2 Ethiopia 59.2 Zimbabwe B. Faso 6.5 Uganda 173
3 Nigeria 49.9 Lesotho Burundi 6.4 Tanzania 155
4 Kenya 43.9 Swaziland Ghana 6.0 Cameroon 147
5 India 41.4 Zambia Thailand 5.6 B. Faso 132
6 Zimbabwe 29.2 Namibia Botswana 5.5 Congo 128
7 Tanzania 25.2 S. Africa CAR 4.9 Cambodia 126
8 DR Congo 22.6 Djibouti Myanmar 4.9 Togo 113
9 Mozam Malawi Lesotho 4.8 DR Congo 105
10 Zambia 18.9 Kenya Haiti 3.7 Nigeria 96
11 Uganda 17.3 CAR Angola 3.1 Haiti 94
12 Malawi 16.1 Mozam Namibia 3.1 Gabon 82
13 C. d'Ivoire 15.0 Burundi China 2.9 Ghana 64
14 Cameroon 10.1 Rwanda Togo 2.4 S. Leone 56
15 Cambodia 7.7 Ethiopia USA 2.3 Angola 56

17. 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.

18. 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

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

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

23. 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

24. 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.

25. Estimated numbers of TB cases by country in 2000

26. 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 (%)

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

28. 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 (%)