Technical update: TB/HIV co-infection and Community Engagement

Alberto Matteelli

THC Unit, Global TB Programme

World Health Organization, Geneva, Switzerland

DEVELOPMENT OF NATIONAL STRATEGIC PLANNING FOR TB CONTROL:

THE CORE COMPONENTS

DIVONNE, FRANCE, 17 – 26 FEBRUARY 2014‏

Photo: Riccardo Venturi

TB/HIV co-infection

TB cases and deaths, 1990–2012 absolute numbers

1.5

0

1.0

0.5

1990 2000 2010 2000 1990 2010

HIV-negative

HIV-positive

All cases

HIV-positive cases

Peak >9 in early 2000s

Total mortality peaked early

2000s at >1.8 million

Incident cases 8.6 million in 2012 Deaths 1.3 million in 2012

10

7.5

5.0

2.5

0

Mil

lio

ns

1.1

Define whether TB/HIV is a priority in your country

• Overlapping of the two epidemics

• HIV prevalence among TB patients

• (TB incidence or prevalence among PLHIV)

• Number of TB/HIV co-infected patients (the burden)

Estimated HIV prevalence in new TB cases - 2012

TB incidence rates in HIV-infected

populations in Africa

(cf 10% lifetime risk for HIV-)

0

2

4

6

8

10

12

14U

gan

da

Rw

an

da

Rw

an

da

Rw

an

da

DR

Co

ng

o

Rw

an

da

Ken

ya

Ken

ya

Zam

bia

S A

fric

a

S A

fric

a

S A

fric

a

Co

te d

'Ivo

ire

Inc

ide

nc

e T

B (

%/y

r)

source: Holmes et al CID 2003

Treatment outcomes for HIV-positive and HIV-negative TB patients, 2011.

WHO Global report 2013

TB is the main killer of HIV infected persons according to autopsy studies

Cox JA, AIDS Rev. 2010; 12: 183-94

Estimated number

of cases

Estimated number of

deaths

HIV-associated TB

1.1 million (13%) (range: 1.0–1.2 million)

320,000 (range: 400,000–460,000)

0–24

25–49

50–99

100–299

300 and higher

No estimate available

Global Burden of TB/HIV - 2012

• Do you know the numbers for your country ?

• If these are estimates, can you measure how many

TB/HIV missing cases you have ?

TB Global report 2013

What interventions, and how to measure the process ?

Clear, solid, evidence-based based policy guidance

An M&E guide under revision in

2014

Collaborative TB/HIV activities - 2012

Priority 1: TB entry side

Priority 2: any entry side

WHO recommendation

• Start ART in all HIV infected individuals with active tuberculosis irrespective of CD4 cell count

(strong recommendation – Low quality of evidence)

TB/HIV guidelines 2012 and

ART consolidated guidelines 2013

Ensure ART treatment during TB treatment

Ref: Global TB Control Report 2013

ART coverage among TB patients

Inequity of ART provision to TB patients

Priority 2: any entry side

TB/HIV guidelines 2012 and

ART consolidated guidelines 2013

Ensure TIMELY ART treatment

WHO recommendation

• Anti-TB treatment should be initiated first, followed by ART as soon as possible within the first 8 weeks of treatment.

• Those TB/HIV patients with profound immunosuppression (e.g. CD4 counts <50 cells cells/mm3) should receive ART immediately within the first 2 weeks of initiating TB treatment.

Priority 3: HIV entry side

IPT

Preventive therapy scale-up: happening but only in a few countries

Nu

mb

er s

tart

ed o

n I

PT

(th

ou

san

ds)

71% of the global total in 2012 in South Africa

Estimated # TB cases prevented by IPT in Botswana

• Assume that efficacy of IPT in TB prevention is 43% (74% if TST positive)*

• Botswana TB cases per year = 7,000 (2012)

• Proportion of these in PLHIV= 63%, so 4,410 HIV-TB cases per year

• # cases prevented in HIV+ each year if all PLHIV received IPT = 43% x 4,410= 1,896

Give correct value to IPT

• HIV services in driving seat with support from TB services

• Target new and old PLHIV who have no TB and did not receive IPT before

• Rule out active TB and rule in IPT by clinical algorithm

• Evaluate if TST feasible or killing agent

• Make it clear that:

Risk of developing drug resistant minimal

Duration of protection optimized by extending duration of treatment where needed

ART does not practically decrease the benefit of IPT

In high H-resistant countries IPT benefit reduced but still significant

Scaling-up IPT

Priority 4: HIV entry side

Diagnose TB early in PLHIV

The cascade of care

With signs/symptoms Initial test Other diagnostic tests Clinical decision

Treat for TB

if positive

Treat for TB

if suggestive

% with presumptive TB % being tested % started on treatment

Monitoring the cascade…….

Xpert MTB/RIF as the initial diagnostic test

ICF

Prevent TB among PLHIV: the 5 Is

Increased ART coverage

Infection control

Integrated TB/HIV services

IPT

Integrated TB/HIV services

• Plan for appropriate development to ensure patient centered care

• Describe your model of care

Kenya: one stop service for TB and HIV

Integrated TB and HIV services at same place and time

14

79

88 91 93

100

17

37 34

48

64

74

0

20

40

60

80

100

120

2005 2007 2009 2010 2011 2012

Percentage of TB patients tested Percentage of HIV positive TB patients on ART

One stop

Results: One stop service model in Rwanda

Decentralisation of services and task shifting to nurses

Percent shows out of all identified HIV positive TB patients nationally

TB nurse

Provides HIV testing

Draws blood for CD4

Provides ART and CPT

0

20

40

60

80

100

120

2005 2006 2007 2008 2009 2010 2011 2012

ART for TB patients CPT for TB patients

Community Engagement

& National Strategic Plans

Why adopt ENGAGE-TB?

• to strengthen and expand community-based TB activities and more effectively utilize the activities of community-based NGO in TB screening, referrals and care

• to increase the number of NGOs engaging in community-based TB by proactive outreach to existing org’s which are currently unengaged in TB, especially those already working in the areas of HIV, MNCH, and PHC and encouraging them to integrate TB into their work.

How does ENGAGE-TB help achieve NSP objectives?

ENGAGE-TB:

• Assists early detection

• Assists treatment support

• Helps prevent TB transmission

• Addresses the social determinants

ENGAGE-TB activities in the NSP

1) conduct a situation analysis in each district to map the potential new organizations that could be engaged in community-based TB activities;

2) support models of integration with HIV, MNCH and PHC to enable subsequent replication and scale-up;

3) develop guidelines and tools as needed to assist NGOs newly engaging in community-based TB activities – WHO ENGAGE-TB implementation manual will guide you on how new organizations can integrate community-based TB activities into their work and collaborate better with national TB programme;

4) provide training to organizations newly engaging in community-based TB activities as may be needed;

ENGAGE-TB activities in the NSP (2)

5) help identify range of TB tasks for each organization to undertake, based on their interests and capacities and NTP needs;

6) ensure regular meetings at every level with these organizations to improve coordination and respond to emerging concerns;

7) explicitly include support to community and NGO engagement in job description and annual performance measurement system of at least one TB official at district and provincial level;

8) provide a small budget at district and provincial levels for quarterly meetings between TB officials and NGOs and systematically follow-up on agreed actions;

ENGAGE-TB activities in the NSP (3)

9) ensure routine recording and reporting of data:

• contribution of community referrals to TB notifications;

• treatment success of patients with community DOT/support

10) assist newly engaged NGOs as well as those as of yet unengaged but working on issues related to TB to form an NGO Coordinating Body for TV at each level (national, province and district) to share information and best practices and to support each other with technical assistance as needed.

11) advocate for increased resources for community-based TB activities at each level and increased representation at the Global Fund’s CCM to influence resources allocation.

Resources

• ENGAGE-TB operational guidance: http://www.who.int/tb/publications/2012/engage_tb_policy/en/index.html

• ENGAGE-TB implementation manual: http://apps.who.int/iris/bitstream/10665/96900/1/9789241506540_eng.pdf

• Ask for more information or technical assistance: ENGAGE-TB@who.int