1. Strategic framework for TB/HIV
Dermot Maher
Stop TB Department
World Health Organization
Geneva, Switzerland
On behalf of the Global TB/HIV Working Group
IUATLD World Conference on Lung Health
Montreal
October 2002

2. Outline of presentation
Why a strategic framework to control TB/HIV?
TB as part of the HIV/AIDS epidemic
Why joint TB and HIV/AIDS programme activities?
What interventions are available against TB/HIV?
Current status of implementation of interventions
A coherent health service response to TB/HIV
Essential package of HIV/AIDS care
From framework to implementation
What is needed for comprehensive action?

3. The burden of HIV-related disease
At any stage
High-grade pathogens, e.g. pneumococcus, non-typhoid salmonellae, Mycobacterium tuberculosis
More advanced immunosuppression
Low-grade pathogens, e.g. candida, Cryptococcus neoformans, toxoplasma, Pneumocystis carinii, atypical mycobacteria

4. How does HIV fuel the TB epidemic?
1. Promotes progression to TB of Mycobacterium tuberculosis infection
- recently acquired
- latent (most powerful known risk factor)
In people co-infected with HIV and Mycobacterium tuberculosis, annual risk of TB = 5-15%
2. Increases rate of recurrent TB (endogenous/exogenous)
3. Increased TB cases in HIV-infected people pose risk of TB transmission to general community.

5. TB/HIV overlapping epidemics
The impact of HIV on the TB epidemic depends on the size of the overlap between the M tuberculosis infected and HIV infected populations
Mycobacterium tuberculosis
HIV
overlap Region HIV epidemic TB/HIV epidemic TB/HIV HIV epidemic overlap
Africa generalised
North America concentrated (IDU, MSM) +
Western Europe
North concentrated (MSM) –
South concentrated (IDU) +
Eastern Europe concentrated (IDU)
TB and HIV

6. Dynamics of TB and HIV in Uganda 160 35 140 30 120 25 100 20
HIV-national
120 25
HIV-Kampala
100 20
HIV prevalence adults
(%)
TB incidence/100,000 80 15 60 10 40 5 20
1975
1980
1985
1990
1995
2000

8. A key fact
At least 1 in 3 people with HIV
will develop TB

9. Implication for HIV/AIDS Programmes
TB is a huge part of HIV/AIDS care

10. Implication for TB Programmes
Prevention of HIV is crucial to control TB

11. Evolving international response to TB/HIV?
Previously - “a dual strategy for a dual epidemic” (UNAIDS)
TB and HIV/AIDS programmes have largely pursued separate courses
Now - unified health sector strategy
Controlling TB/HIV as an integral part of response to HIV/AIDS.

12. Sequence of events in transmission of TB
Transmission of infection
M. tuberculosis infection
Recurrence after treatment
Inadequate treatment
M. tuberculosis infected person
Untreated
Active TB
TB progression
TB reactivation

13. Sequence of events by which HIV fuels TB
Transmission of infection
M. tuberculosis infection
HIV infection
Recurrence after treatment
Inadequate treatment
M. tuberculosis infected person
Untreated
Active TB
TB progression
TB reactivation

14. Main biomedical interventions against M tuberculosis
Transmission of infection
M. tuberculosis infection
TB preventive treatment
HIV infection
Recurrence after treatment
BCG
Rifampicin
containing regimens
Inadequate treatment
M. tuberculosis infected person
 Intensified case-finding
 Decreased diagnostic & treatment delays
Untreated
Intervention against M.tuberculosis
Active TB
TB progression
Sequence of events:
HIV-negative
HIV-positive
TB reactivation
TB preventive treatment

15. Main interventions to interrupt the sequence of events by which HIV fuels TB
Transmission of infection
M. tuberculosis infection
TB preventive treatment
HIV infection
Condoms STI treatment
Safe IDU
Recurrence after treatment
BCG
Rifampicin
containing regimens
Inadequate treatment
M. tuberculosis infected person
 Intensified case-finding
 Decreased diagnostic & treatment delays
HAART
Untreated
Intervention against HIV
Intervention against M.tuberculosis
Active TB
TB progression
Sequence of events:
HIV-negative
HIV-positive
TB reactivation
TB preventive treatment

16. Expanded scope of new strategy to control TB in high HIV prevalence populations
Intensified TB case-finding and treatment
Additional measures beyond TB case-finding and treatment
TB preventive therapy
Interventions to decrease morbidity and mortality in HIV-infected TB patients
Interventions to decrease HIV transmission
ARV therapy

17. Status of implementation of interventions in sub-Saharan Africa in 2001
1) Condoms
annual provision = 5 per man per year (17 in top 6 countries)
2 billion per year needed for all countries to match top 6
(Shelton JD, Johnston B. Br Med J 2001; 323: 139)

18. HIV-infected people treated with HAART = 30,000
2) Antiretrovirals
HIV-infected people treated with HAART = 30,000
(out of 30 million)

19. 3) NTP performance in 24 countries with adult HIV seroprevalence > 5%
Countries achieving WHO target successful treatment rate of 85% (corrected for high case fatality)
Malawi
Haiti (40%)

20. A coherent health service response to TB/HIV (1)
Strengthened TB programme activities
Strengthened HIV/AIDS programme activities
Joint TB and HIV/AIDS programme activities
planning
surveillance
training staff
drug supply and other logistics
case detection and management

21. A coherent health service response to TB/HIV (2)
Essential package of HIV/AIDS care in low-income countries
Interventions including TB interventions at relevant levels of health care system:
home and community care
primary care
secondary care
tertiary care
Criteria for prioritisation, e.g. cost-effectiveness
TB treatment is one of the most cost-effective HIV/AIDS interventions
(Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Creese et al. Lancet 2002; 359: )

22. From a strategic framework to national implementation strategies
Stop TB Dept HIV/AIDS Dept UNAIDS
national partners
field experience (e.g. ProTEST Initiative)
national implementation strategy
strategic framework
wide consultation and endorsement by Global TB/HIV Working Group
the evidence for what is possible
who does what, when, with which funds, from where?

23. Needs in strengthening general health service providers
Increased funding for improved general health service provider capacity (human resources, infrastructure, commmodities)
Shift in policy:
away from vertical HIV/AIDS services
towards a strengthened response to meet the needs of high HIV prevalence populations
Operational research on TB and HIV programme collaboration in supporting health providers
Effective coordination of many role players

24. Conclusion
Increasing aid flows for priority diseases of poverty (AIDS, TB and malaria):
HIPC
GF ATM
Foundations, e.g. Gates
commitment + $ + action -> results