Photo: Riccardo Venturi TB and HIV The deadly dual epidemic Hannah Monica Yesudian Dias Global TB Programme World Health Organization Geneva, Switzerland GLOBAL TB PROGRAMME
Overview TB basics TB situation, global response and progress The TB/HIV co-epidemic and response GLOBAL TB PROGRAMME
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. GLOBAL TB PROGRAMME
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 GLOBAL TB PROGRAMME
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 GLOBAL TB PROGRAMME
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 GLOBAL TB PROGRAMME
Treatment • TB is treatable and curable, even in people living with HIV • First line drugs • Four antibiotics over 6-8 months • Drug resistance GLOBAL TB PROGRAMME
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 GLOBAL TB PROGRAMME
The Global Burden of TB -2012 Estimated number Estimated number of cases of deaths 8.6 million 1.3 million* All forms of TB 0.5 m in children 74.000 in children • • • 2.9 m in women • 410.000 in women 1.1 million (13%) 320,000 HIV-associated TB Multidrug-resistant TB 450.000 170,000 Source: WHO Global Tuberculosis Report 2013 * Including deaths attributed to HIV/TB GLOBAL TB PROGRAMME
Estimated TB incidence rate, 2012 Americas Europe Ref: Global TB Control Report 2013 3% 4% E. Mediterranean 8% South-East Asia 39% Africa 27% 38% in India + China 26% in India Western Pacific 19% GLOBAL TB PROGRAMME
Percentage of new TB cases with MDR-TB Globally 3.6% Ref: Global TB Control Report 2013 GLOBAL TB PROGRAMME
92 countries notified at least one case of XDR-TB by the end of 2012 Ref: Global TB Control Report 2013 GLOBAL TB PROGRAMME
The global response: Stop TB Strategy & Global Plan To save lives, prevent suffering, protect the vulnerable, and promote human rights GLOBAL TB PROGRAMME
THE WHO STOP TB STRATEGY Address TB/HIV Strengthen systems Pursue DOTS and MDR-TB Promote research Engage all Empower care providers communities GLOBAL TB PROGRAMME
The Global TB Control Targets 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) 2015: 50% reduction in TB deaths among people living with HIV GLOBAL TB PROGRAMME
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 GLOBAL TB PROGRAMME
Key challenges Case detection TB/HIV co infection Multidrug - resistant TB A third of cases not Special challenge in Africa Special challenge in Eastern diagnosed or reported Europe Weak health policies, systems, Under-engaged Bottlenecks for financing of financing, and services communities and research and innovation providers GLOBAL TB PROGRAMME
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 of drug-resistant TB GLOBAL TB PROGRAMME
Estimated HIV prevalence among new TB cases Around 75% of all estimated TB/HIV cases are in Africa Ref: Global TB Control Report 2013 GLOBAL TB PROGRAMME
Collaborative TB/HIV activities 2012 GLOBAL TB PROGRAMME
1.3 million lives saved globally by the implementation of TB/HIV interventions, 2005-2011 Blue band represents the uncertainty interval GLOBAL TB PROGRAMME
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 GLOBAL TB PROGRAMME
Collaboration and Integration Co-location Joint monitoring GLOBAL TB PROGRAMME
Strong TB/HIV collaboration within health systems GLOBAL TB PROGRAMME
B. Decrease burden of TB in PLHIV Intensified Isoniazid Preventive TB screening diagnosis Therapy Infection Control GLOBAL TB PROGRAMME
Provision of isoniazid preventive therapy (IPT) to people living with HIV without active TB, 2005-2012 GLOBAL TB PROGRAMME
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 GLOBAL TB PROGRAMME
HIV testing for notified TB patients Percentage of TB patients with known HIV status, 2004-2012 GLOBAL TB PROGRAMME
C.5.Antiretroviral Therapy • ART for all TB patients living with HIV • Improves quality and survival of life. • Reduce incidence of TB by >80% GLOBAL TB PROGRAMME
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. GLOBAL TB PROGRAMME
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 GLOBAL TB PROGRAMME
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 of 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 GLOBAL TB PROGRAMME
“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 GLOBAL TB PROGRAMME
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