TB and HIV The deadly dual epidemic Hannah Monica Yesudian Dias - - PowerPoint PPT Presentation

TB and HIV

The deadly dual epidemic

GLOBAL TB

PROGRAMME Hannah Monica Yesudian Dias Global TB Programme World Health Organization Geneva, Switzerland

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TB basics TB situation, global response and progress The TB/HIV co-epidemic and response Overview

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What is tuberculosis (TB)?

• Caused by infection with a bacteria

– Mycobacterium tuberculosis

• 1/3 of the world’s population are

infected with TB (not active disease)

• Only 5-10% actually develop TB disease

during their lifetime (if HIV negative)

• TB is a disease of poverty affecting

mostly young adults in their most productive years.

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Clinical features

• Latent TB infection progresses to disease when

body’s immune system weakened

• TB disease usually affects the lungs (pulmonary

TB) but can affect any other part of the body (extrapulmonary TB).

• Symptoms

– persistent cough – weight loss – fever – night sweats – coughing up blood

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Diagnosis

• Microscopy of specially stained sputum is

the main test for diagnosing TB

• Test is not as effective in HIV/ children

– sputum negative TB – extrapulmonary TB

• Culture and drug susceptibility testing
• X-ray
• Xpert MTB/Rif test

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Prevention

• TB can be prevented

 Intensified case finding  Better TB control services  Infection control

• HIV care
• Prisons
• Workplace
• Health care settings

 Better housing, sanitation, nutrition

• Isoniazid preventive therapy

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Treatment

• TB is treatable and curable, even in

people living with HIV

• First line drugs
• Four antibiotics over 6-8 months
• Drug resistance

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Drug-resistant TB

• Multi-drug resistance (MDR)

 Treat with second-line drugs  Treating MDR TB takes 3-4 times longer and costs 100 times more

• Extensively drug resistant TB (XDR-TB)

 Difficult to diagnose  High fatality rate in people living with HIV

Drug resistant TB results from inadequate TB control and irrational use of drugs

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Estimated number

• f cases

Estimated number

• f deaths

1.3 million*

• 74.000 in children
• 410.000 in women

8.6 million

• 0.5 m in children
• 2.9 m in women

450.000

All forms of TB Multidrug-resistant TB HIV-associated TB

1.1 million (13%) 320,000

Source: WHO Global Tuberculosis Report 2013 * Including deaths attributed to HIV/TB

The Global Burden of TB -2012

170,000

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South-East Asia

39%

Western Pacific

19%

Africa

27%

• E. Mediterranean

8%

Europe

4%

Americas

3%

38% in India + China 26% in India

Ref: Global TB Control Report 2013

Estimated TB incidence rate, 2012

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Percentage of new TB cases with MDR-TB

Globally 3.6%

Ref: Global TB Control Report 2013

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92 countries notified at least one case of XDR-TB by the end of 2012

Ref: Global TB Control Report 2013

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The global response: Stop TB Strategy & Global Plan

To save lives, prevent suffering, protect the vulnerable, and promote human rights

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Pursue DOTS Address TB/HIV and MDR-TB Strengthen systems

THE WHO STOP TB STRATEGY

Engage all care providers Empower communities Promote research

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2015: Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6c: to have halted by 2015 and begun to reverse the incidence… *Indicator 6.9: incidence, prevalence and mortality associated with TB *Indicator 6.10: proportion of TB cases detected and cured under DOTS 2015: 50% reduction in TB prevalence and deaths 2050: elimination (<1 case per million population)

The Global TB Control Targets

2015: 50% reduction in TB deaths among people living with HIV

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Global Progress on impact

 56 million patients cured, 1995-2011  22 million lives saved since 1995  2015 MDG target on track  BUT, TB incidence declining too slowly  3 million missing  MDR crisis

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Key challenges

Bottlenecks for financing of research and innovation Case detection

A third of cases not diagnosed or reported

TB/HIV co infection

Special challenge in Africa

Multidrug - resistant TB

Special challenge in Eastern Europe

Weak health policies, systems, financing, and services Under-engaged communities and providers

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TB/HIV: the deadly co-epidemic

• TB is a leading cause of death among people living

with HIV. One in five HIV related deaths are due to TB.

• One third of the 35.3 million people living with HIV

are infected with latent TB

• People who are HIV-positive and infected with

latent TB are 30 times more likely to develop active TB than people not infected with HIV.

• Untreated TB in people living with HIV leads to

death in weeks

• People living with HIV are facing emerging threats
• f drug-resistant TB

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Estimated HIV prevalence among new TB cases

Around 75% of all estimated TB/HIV cases are in Africa

Ref: Global TB Control Report 2013

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Collaborative TB/HIV activities 2012

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1.3 million lives saved globally by the implementation

• f TB/HIV interventions, 2005-2011

Blue band represents the uncertainty interval

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• A. Establish Mechanism for

integrated TB and HIV services

• Coordinating bodies: needed for effective TB and HIV programme efforts

collaboration at all levels.

• Harmonized HIV surveillance among TB patients: Essential to inform

programme planning and implementation

• Joint TB/HIV strategic planning to collaborate successfully and

systematically.

• Monitoring and evaluation, crucial to provide the means to assess quality,

effectiveness, coverage and delivery

• Models of integrated delivery of HIV and TB services

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Collaboration and Integration

Co-location Joint monitoring

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Strong TB/HIV collaboration within health systems

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Infection Control Isoniazid Preventive Therapy

TB diagnosis

Intensified screening

• B. Decrease burden of TB in PLHIV

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Provision of isoniazid preventive therapy (IPT) to people living with HIV without active TB, 2005-2012

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• C. Decrease burden of HIV among TB patients
• HIV testing: offers an entry point for a

continuum of TB and HIV/AIDS prevention, care, support and treatment.

• All TB patients and patients with signs and

symptoms should be tested for HIV.

• Couple HIV testing and counselling
• HIV preventive methods
• Cotrimoxazole preventive therapy (CPT)
• Care and support

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HIV testing for notified TB patients

Percentage of TB patients with known HIV status, 2004-2012

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C.5.Antiretroviral Therapy

• ART for all TB patients living with HIV
• Improves quality and survival of life.
• Reduce incidence of TB by >80%

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Percentage of TB patients with known HIV status who were HIV positive, percentage of HIV-positive TB patients enrolled on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART), 2006-2012*

* The solid lines show values for countries that reported data. The shaded areas show upper and lower limits when countries that did not report data are considered.

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Global health sector strategy, 2011-2015 Consolidated ARV guidelines, June 2013

• HIV/TB is key priority area
• Focus remains on 12 collaborative activities and the Three I's for HIV/TB
• Focus on integration

Consolidated ARV guidelines:  ART should be initiated in all individuals with HIV regardless of WHO clinical stage or CD4 cell count in the following situations:

 Individuals with HIV and active TB disease  Individuals coinfected with HIV and HBV (hepatitis B virus) with evidence of severe chronic liver disease  Pregnant women and children under 5  Partners with HIV in serodiscordant couples should be offered ART to reduce HIV transmission to uninfected partners

 Earlier ART for PLHIV: under 500 CD4 count with a priority for those under 350  Community engagement high priority  Integrated approach to TB and HIV and health service delivery

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Conclusion

• TB and HIV inextricably linked
• TB is usually treatable and curable in people living with HIV
• Universal access to HIV services means access also to prevention, care and treatment
• f TB

– TB prevention, diagnosis and treatment should be essential component of HIV care and treatment – IPT is important

• Delivery of integrated TB and HIV services at the same time an place as much as

possible is crucial

• All TB and HIV stakeholders including corporations & communities need to work very

closely together to reduce the impact of TB on people living with HIV

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“We c a n’ t fig ht AI DS unle ss we do muc h mo re to fig ht T B a s we ll."

Ne lso n Ma nde la Ba ng ko k, July 15, 2004

Source: From the CREATE project Nelson Mandela, Former President of South Africa and Nobel peace prize winner 1993

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Resources

• WHO policy on collaborative TB/HIV activities (2012)
• Three interlinked patient monitoring systems for HIV care/ART, MCH/PMTCT (including malaria

prevention during pregnancy), and TB/HIV: standardized minimum data set and illustrative tools (2013)

• WHO policy on intensified TB case finding and isoniazid preventive therapy (2011)
• Technical and practical “how to” considerations for rapid implementation of the Xpert MTB/RIF

diagnostic test which includes an algorithm relating to the diagnosis of HIV associated TB (2011)

• The consolidated guidelines on the use of antiretrovirals for the treatment and prevention of HIV

infection (2013)

• Policy guidelines for Collaborative HIV and TB Services for Injecting Drug Users (2008)
• Policy guidelines on Infection Control (2009)

www.who.int/tb Factsheets: http://www.who.int/tb/publications/factsheets/en/index.html

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Thank you and Questions