TB Working Group_Kayt E_10.13.11


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  • India and China do not have the highest rates of TB, but due to population numbers they contribute 40% of all TB cases globally
  • 2009 (from 2010 report) All forms of TB, 9.4M cases, 1.7M deaths HIV-Associated TB: 1.1M cases, 380K deaths MDR-TB: 440K cases, ~150K deaths
  • The number of cases is the same estimate as last year, but mortality estimates have dropped from 400,000 in 2009 to 350,000 in 2010.
  • The geographical distribution of this tragedy is uneven, as sub-Saharan Africa has to suffer 80% of the burden, with several countries reporting over 10,000 deaths for the co-infection per year, and South Africa over 80,000. However, India has a large burden as well.
  • The estimated annual TB incidence per 100,000 adults increases in a proportional way with the HIV prevalence in adults, 15-49 years of age. When HIV prevalence increases by 1%, the TB incidence increases by 26/100,000 per year.
  • 2010 All forms of TB, 9.4M cases, 1.7M deaths HIV-Associated TB: 1.1M cases, 380K deaths MDR-TB: 440K cases, ~150K deaths
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  • TB Working Group_Kayt E_10.13.11

    1. 1. TB/HIV Why do we care about the intersection of the epidemics? Kayt Erdahl, Technical Officer HIV/AIDS & TB Global Programs, PATH CORE Group Fall Meeting October 13, 2011
    2. 2. Contents <ul><li>Background </li></ul><ul><ul><li>Basic TB facts </li></ul></ul><ul><ul><li>Global TB and TB/HIV burden </li></ul></ul><ul><ul><li>Why should we care about TB/HIV? </li></ul></ul><ul><li>Global strategies for addressing TB/HIV </li></ul><ul><ul><li>Interim policy on collaborative TB/HIV activities </li></ul></ul><ul><ul><li>“ The Three I’s” </li></ul></ul><ul><ul><li>What is PATH doing? </li></ul></ul>
    3. 3. Basic TB facts <ul><li>Tuberculosis (TB) is a contagious, air-borne disease caused by a bacteria called Mycobacterium tuberculosis . </li></ul><ul><li>It primarily affects the lungs but can also affect any other part of the body. </li></ul><ul><li>It is spread through the air when someone with active TB disease coughs, sneezes, etc. </li></ul><ul><li>TB is curable, with effective, low-cost treatment available worldwide. </li></ul>
    4. 4. Basic TB facts <ul><li>About 1/3 of the world's population, 2 billion people, are infected with Mycobacterium tuberculosis </li></ul><ul><ul><li>10% lifetime risk of active disease </li></ul></ul><ul><li>Each year, almost 9 million people become ill from TB </li></ul><ul><ul><li>1.1 million of them are people living with HIV/AIDS </li></ul></ul><ul><ul><li>1.4 million die </li></ul></ul><ul><li>Worldwide, TB is the greatest single infectious cause of death in young women. </li></ul><ul><li>TB is the second leading infectious cause of death worldwide, after HIV. </li></ul><ul><li>TB disproportionately affects the poor </li></ul>
    5. 5. Global burden of TB
    6. 6. High Burden Countries (HBC) 22 countries account for 80% of the world’s burden of TB <ul><li>India </li></ul><ul><li>China </li></ul><ul><li>Indonesia </li></ul><ul><li>South Africa </li></ul><ul><li>Nigeria </li></ul><ul><li>Bangladesh </li></ul><ul><li>Ethiopia </li></ul><ul><li>Pakistan </li></ul><ul><li>Philippines </li></ul><ul><li>DR Congo </li></ul><ul><li>Russian Federation </li></ul><ul><li>Vietnam </li></ul><ul><li>Kenya </li></ul><ul><li>Tanzania </li></ul><ul><li>Uganda </li></ul><ul><li>Brazil </li></ul><ul><li>Mozambique </li></ul><ul><li>Thailand </li></ul><ul><li>Myanmar </li></ul><ul><li>Zimbabwe </li></ul><ul><li>Cambodia </li></ul><ul><li>Afghanistan </li></ul>Data source: WHO Global TB Report 2011 40% of all TB cases
    7. 7. Global Burden of TB and TB/HIV, 2010 *Including deaths among people living with HIV Data from WHO Global TB Report, 2011 Estimated number of cases Estimated number of deaths All forms of TB 8.8 million 1.4 million* All forms of TB, women only 3.2 million 320,000 HIV-Associated TB 1.1 million 350,000 Multidrug-resistant TB (MDR-TB) 650,000 ~150,000 (2008)
    8. 8. Why should we care about TB/HIV? <ul><li>People with HIV are dying from TB! </li></ul><ul><li>HIV makes TB disease more likely to develop among people infected with TB, and harder to diagnose when they do have disease </li></ul><ul><li>TB kills people living with HIV faster </li></ul><ul><li>TB advances are being rolled back, especially in Africa, by expansion due to the HIV epidemic </li></ul><ul><li>About 13% of TB cases occur among PLHWA </li></ul><ul><li>TB is responsible for one in four AIDS deaths </li></ul>
    9. 9. Estimated HIV prevalence in new TB cases, 2010 WHO, Global TB Report 2011 1.1 million TB/HIV cases and 350,000 deaths
    10. 10. Countries with the highest number of deaths from HIV-associated TB Time to act - Save a million lives by 2015 Prevent and treat tuberculosis among people living with HIV. WHO 2011
    11. 11. 41 TB/HIV High Burden Countries (HBC) <ul><li>Vietnam </li></ul><ul><li>Kenya </li></ul><ul><li>Tanzania </li></ul><ul><li>Uganda </li></ul><ul><li>Brazil </li></ul><ul><li>Mozambique </li></ul><ul><li>Thailand </li></ul><ul><li>Myanmar </li></ul><ul><li>Zimbabwe </li></ul><ul><li>Cambodia </li></ul><ul><li>Afghanistan </li></ul>Countries in bold are also HBC for TB; Data source: WHO Global TB Report 2011 1 Angola 15 Ethiopia 29 Rwanda 2 Botswana 16 Ghana 30 Sierra Leone 3 Brazil 17 Haiti 31 South Africa 4 Burkina Faso 18 India 32 Sudan 5 Burundi 19 Indonesia 33 Swaziland 6 Cambodia 20 Kenya 34 Thailand 7 Cameroon 21 Lesotho 35 Togo 8 Ctrl African Rep 22 Malawi 36 Uganda 9 Chad 23 Mali 37 Ukraine 10 China 24 Mozambique 38 UR Tanzania 11 Congo 25 Myanmar 39 Viet Nam 12 Cote d’Ivoire 26 Namibia 40 Zambia 13 Djibouti 27 Nigeria 41 Zimbabwe 14 DR Congo 28 Russia
    12. 12. Estimated TB incidence vs. HIV prevalence in high burden countries 0 400 800 1200 1600 0.0 0.1 0.2 0.3 0.4 HIV prevalence, adults 15-49 years Estimated annual TB incidence (per 100K adults , 1999) As HIV prevalence increases by 1%, TB incidence increases by 26/100k/yr Williams B. 3rd Global TB/HIV Working Group Meeting; Montreux, 4-6 June 2003
    13. 13. TB/HIV Data from WHO Global TB 2011 Report <ul><li>HIV testing of TB patients is now standard practice in many countries, especially in Africa. In 2010, 34% of notified TB patients knew their status. </li></ul><ul><li>Global coverage of ART for TB/HIV patients remains low at 46%, despite a large increase in HIV testing of TB patients </li></ul>In 2010 2.3 M PLHIV screened for TB (58% of PLHIV) 178,000 PLHIV enrolled on IPT (12% of newly enrolled PLHIV)
    14. 14. Global Plan to Stop TB 2011-2015 Summary of main TB/HIV indicators Data from WHO Global TB Report, 2011 TB/HIV indicators Baseline (2009) 2010 % TB patients tested for HIV 26% 34% % HIV+ TB patients treated with CPT 75% 77% % of HIV+ TB patients treated with ART 37% 46% % of PLHA attending HIV care services who were screened for TB at their last visit ~25% 58% % of PLHA attending HIV care services who were enrolled on IPT; among those eligible <1% 12%
    15. 15. Funding disparities <ul><li>Donor funding for TB </li></ul><ul><li>2012 anticipated: $0.6 billion, 50% higher than 2006 at $0.4 billion. </li></ul><ul><li>Far short of funding provided to Malaria and HIV/AIDS in 2010: </li></ul><ul><ul><li>Malaria $1.8 billion, HIV/AIDS $6.9 billion </li></ul></ul><ul><li>Treatment: With the threat of MDR and XDR-TB, there are less drugs available, they are much more expensive, have worse side effects and treatment is 4 times longer – 2 years instead of 6 months. </li></ul><ul><li>TB R&D: “The field of research on TB has really missed generations of advances in biology and technology. We really need to bring TB research from the 19th into the 21st century,” -Anthony S. Fauci, director of the NIAID at the release of the WHO Global TB Report 2011. </li></ul>
    16. 16. <ul><li>A. Establish the mechanism for integrated TB& HIV services </li></ul><ul><ul><li>Set up coordinating bodies for effective TB/HIV activities </li></ul></ul><ul><ul><li>at all levels </li></ul></ul><ul><ul><li>Conduct surveillance of HIV prevalence among TB cases </li></ul></ul><ul><ul><li>Carry out joint TB/HIV planning </li></ul></ul><ul><ul><li>Conduct monitoring and evaluation </li></ul></ul><ul><li>B. Decrease burden of TB among PLHIV (the &quot;3 Is&quot;) </li></ul><ul><ul><li>Establish I ntensified TB case finding and ensure quality TB treatment </li></ul></ul><ul><ul><li>Introduce TB prevention with I soniazid Preventive Therapy (or ART) </li></ul></ul><ul><ul><li>Ensure TB I nfection control in health care and congregate </li></ul></ul><ul><ul><li>settings </li></ul></ul><ul><li>C. Decrease burden of HIV among TB patients </li></ul><ul><ul><li>Provide HIV testing and counselling to TB suspects & TB patients </li></ul></ul><ul><ul><li>Introduce HIV prevention methods for TB suspects & TB patients </li></ul></ul><ul><ul><li>Provide CPT for TB patients living with HIV </li></ul></ul><ul><ul><li>Ensure HIV prevention; treatment & care for TB patients with HIV </li></ul></ul><ul><ul><li>Introduce ARVs to TB patients living with HIV </li></ul></ul>TB/HIV collaborative activities: a 12 points package
    17. 17. Reducing TB burden among PLWHA Isoniazid preventive therapy Infection control Intensified case finding Adapted from WHO; 2009 The 3 Is Antiretroviral therapy The 4 th I
    18. 18. The Three I’s <ul><li>I ntensified TB case-finding (ICF) - Screening and diagnosing TB in people living with HIV can be challenging but TB is curable in people living with HIV/AIDS. </li></ul><ul><li>I soniazid preventive therapy (IPT) – Treating TB infection in people who don’t have active TB disease can reduce the burden of TB among PLHWA </li></ul><ul><li>I nfection control (IC) – Strengthening IC measures to reduce airborne TB transmission. </li></ul>
    19. 19. 2011 WHO Recommendations on collaborative TB/HIV activities <ul><li>Intensified TB case-finding </li></ul><ul><li>Isoniazid preventive therapy (IPT) </li></ul>
    20. 20. Intensified case finding (ICF) <ul><li>ICF leads to diagnosis and treatment of TB; increasing the chances of survival, improving the quality of life and reducing the spread of TB among people living with HIV. </li></ul><ul><li>Screening and diagnosing TB in people living with HIV can be challenging but TB is curable in people living with HIV. </li></ul><ul><li>4-symptom Screening for TB in PLWHA: </li></ul><ul><ul><li>current cough, fever, weight loss or night sweats </li></ul></ul>
    21. 21. Isoniazid Preventive Therapy (IPT) <ul><li>Isoniazid Preventive Therapy (IPT) involves giving isoniazid to people living with HIV, who also have latent TB infection, to reduce the risk of developing active TB </li></ul><ul><li>Combined use of IPT and antiretroviral therapy among people living with HIV significantly reduces the incidence of TB disease </li></ul><ul><li>Current standard (IPT): Isoniazid 300 mg /daily for 6-9 months </li></ul><ul><li>Should be a core function of HIV services </li></ul>
    22. 22. TB/HIV interventions scale-up by HIV/AIDS programmes In 2008 1.4 M PLHIV screened for TB (4% of PLHIV) 56,000 PLHIV enrolled on IPT (0.2% of PLHIV)
    23. 23. What is infection control? <ul><li>Prevention of TB transmission </li></ul><ul><li>Patient to Worker to Visitor to </li></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul>Patient Worker Visitor
    24. 24. Infection Control <ul><li>Environmental Controls </li></ul><ul><li>Equipment or practices to reduce the concentration of infectious bacilli in air in areas where contamination of air is likely. </li></ul><ul><li>Ventilators </li></ul><ul><li>UV lamps </li></ul><ul><li>Open windows </li></ul><ul><li>Personal </li></ul><ul><li>Protection </li></ul><ul><li>Respiratory protection is used to protect personnel who must work in environments with contaminated air. </li></ul><ul><li>Masks </li></ul><ul><li>N95 Respirators </li></ul><ul><li>Administrative Controls </li></ul><ul><li>Policies and work practices to reduce risk of exposure, infection, and disease. </li></ul><ul><li>Cough monitors </li></ul><ul><li>Outdoor waiting area </li></ul><ul><li>Scheduling services at different times </li></ul>
    25. 25. <ul><li>Questions? </li></ul>