1. HIV Testing for TB Patients in the Context of ART Scale-Up - Barriers to Implementation Kevin M. De Cock, MD CDC Kenya Geneva, February 14, 2005

2. HIV, Viral Load, and CD4+; The Locomotive Model

3. ARV Scale-up – The Locomotive Model

4. Barriers to HIV Testing International will and leadership National will and leadership Written policies and guidelines (HIV testing; HIV/TB; ARV) Training curriculum and plan Implementation of training for HCW Human resources Physical infrastructure Procurement and supply of test kits Follow-up and referral Prevention, stigma, discrimination, confidentiality

5. Barriers to HIV Testing International will and leadership National will and leadership Written policies and guidelines (HIV testing; HIV/TB; ARV) Training curriculum and plan Implementation of training for HCW Human resources Physical infrastructure Procurement and supply of test kits Follow-up and referral Prevention, stigma, discrimination, confidentiality

7. New Initiatives – PEPFAR and Three by Five PEPFAR Authorized under The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act (2003) $15 billion over 5 years (two thirds for 15 focus countries) Care for 10 million; prevention of 7 million infections; ARV treatment for 2 million Three by Five Announced in 2003 Aims to provide ARV therapy to 3 million persons in developing countries by end-2005 Based on standardized approaches; sustained country support; global leadership and advocacy Current funding gap $5 billion (2004)

8. Categories of HIV Testing Voluntary counseling and testing Routine HIV testing Diagnostic HIV testing Mandatory HIV testing

9. Routine Screening for HIV Infection — Timely and Cost-Effective Volume 352:620-621 February 10, 2005 Number 6 Cost-Effectiveness of Screening for HIV in the Era of Highly Active Antiretroviral Therapy Expanded Screening for HIV in the United States — An Analysis of Cost-Effectiveness

10. Uptake of PMCT Testing by Testing Strategy, Kisumu, 03-04

12. Contents of Kenya MOH Guidelines on HIV Testing in Clinical Settings Types of HIV testing Settings Consent Who may perform an HIV test Laboratory standards Communication of HIV results Confidentiality and disclosure Special considerations for Research and Surveillance

13. “Failure to provide HIV testing when symptoms or signs of HIV disease may be present is substandard care and is not acceptable.” Guidelines for HIV Testing in Clinical Settings – Kenya Ministry of Health (2004)

14. WHO Recommended First and Second Line ARV Regimens For Failure on: - d4T or ZDV + - 3TC + - NVP or EFV Change to: -TDF or ABC + - ddI + - LPV/r or SQV/r

15. WHO Recommendations for Starting Antiretroviral Therapy If CD4+ available: -WHO stage IV disease -WHO stage III disease, CD4+ <350/cu mm -CD4+ <200/cu mm If CD4+ unavailable: -WHO stage III and stage IV disease -WHO stage II, TLC <1200/cu mm (WHO, 2003)

16. ARV Regimens for Patients on Tuberculosis Therapy Rifampin-based Therapy -Delay till Rifampin completed -(d4T, ZDV), 3TC, EFV -Replace EFV with SQV/RTV LPV/RTV ABC Non-Rifampin-based Therapy - No restrictions

17. Efficacy of TB Treatment Regimens IUATLD Clinical Trial 6-month with RIF throughout 2.2% 5% 8-month with RIF in intensive phase only 7.8% 27% Rate of Adverse Outcomes HIV status Negative Positive Jindani, Nunn, Enarson, Lancet 2004

18. Barriers to HIV Testing International will and leadership National will and leadership Written policies and guidelines (HIV testing; HIV/TB; ARV) Training curriculum and plan Implementation of training for HCW Human resources Physical infrastructure Procurement and supply of test kits Follow-up and referral Prevention, stigma, discrimination, confidentiality

19. Training Curriculum and Implementation for HIV Testing in Clinical Settings

20. Barriers to HIV Testing International will and leadership National will and leadership Written policies and guidelines (HIV testing; HIV/TB; ARV) Training curriculum and plan Implementation of training for HCW Human resources Physical infrastructure Procurement and supply of test kits Follow-up and referral Prevention, stigma, discrimination, confidentiality

21. Human Resources SS Africa has low HCW density and high mortality SS Africa has one tenth HCW density of Europe SS Africa must triple current HCW number (increase of 1 million) (Chen et al, Lancet 2004)

22. Barriers to HIV Testing International will and leadership National will and leadership Written policies and guidelines (HIV testing; HIV/TB; ARV) Training curriculum and plan Implementation of training for HCW Human resources Physical infrastructure Procurement and supply of test kits Follow-up and referral Prevention, stigma, discrimination, confidentiality

24. Barriers to HIV Testing International will and leadership National will and leadership Written policies and guidelines (HIV testing; HIV/TB; ARV) Training curriculum and plan Implementation of training for HCW Human resources Physical infrastructure Procurement and supply of test kits Follow-up and referral Prevention, stigma, discrimination, confidentiality

25. By the numbers Scenario 1: VCT To provide treatment to this many people… We’ll need to identify this many who are HIV+… Which means we’ll need to test this many (% of population)… In Botswana 33,000165,000 401,000 (27%) In Kenya 250,0001,250,000 19,000,000 (60%) In Guyana 1,8009,000 545,000 (78%) Assumptions: 20% of HIV+ need treatment Yield for testing = adult prevalence

26. Options for Treatment, Follow-Up and Referral of HIV+ Tuberculosis Patients Delay ARV till TB therapy completed Delay ARV till rifampicin completed Start ARV in TB clinic as early as feasible Run integrated TB and HIV/AIDS clinics Run separate TB and HIV/AIDS clinics with strong referral links

27. Barriers to HIV Testing International will and leadership National will and leadership Written policies and guidelines (HIV testing; HIV/TB; ARV) Training curriculum and plan Implementation of training for HCW Human resources Physical infrastructure Procurement and supply of test kits Follow-up and referral Prevention, stigma, discrimination, confidentiality

28. Frontiers in HIV Prevention in the Era of ARV Treatment Prevention for positives HIV disclosure Partner notification Discordant couples

29. HIV Discordancy in Couples in Kenya DHS - 2003 89% couples both negative 4% couples both positive 7% discordant 47% infected persons have negative partner Many HIV infections occur in stable couples

30. Neglected Rights, Forgotten Duties Individual Rights To be born free of HIV To remain HIV-negative To know HIV status Access to treatment and care if HIV-infected Protection against discrimination Confidentiality and privacy Individual Duties To know HIV status Not to transmit HIV State Duties To protect and promote the public health To prevent discrimination To provide HIV prevention and care

31. “Let us give publicity to HIV/AIDS and not hide it, because the only way to make it appear like a normal illness like TB, like cancer, is always to come out and say somebody has died because of HIV/AIDS and people will stop regarding it as something extraordinary.” (Nelson Mandela, January 2005)

32. Implementation of HIV Testing for TB Patients