world health organization western pacific region from mekong to bali: scale up of hiv/tb...

World Health Organization

Western Pacific Region

From Mekong to Bali: Scale From Mekong to Bali: Scale up of HIV/TB Collaborative up of HIV/TB Collaborative

ActivitiesActivitiesin Asia Pacific. Key Outcomes in Asia Pacific. Key Outcomes

What next for Asia?What next for Asia?

Massimo N GhidinelliMassimo N Ghidinelli

HSI WPROHSI WPRO

The 15th Core Group Meeting of the TB/HIV Working Group

3-4 November 2009, Chateau de Penthes - Geneva



Outline

• From Mekong (2004) to Bali (2009). Context, objectives, and highlights of TB/HIV regional consultations

• Progress in implementing collaborative activities

• Observations and Conclusions



From Mekong to Bali: The Scale up of TB/HIV Collaborative Activities in Asia Pacific Region 8-9 August 2009, Bali

127 persons from 18 countries from Asia-Pacific



Objectives/Sessions• Review progress and lessons learned since 2004 Greater Mekong

meeting. Update on regional policy and strategies, review of successful collaborative TB/HIV activities

• Review successes and challenges and measures to enhance collaboration between TB and HIV programmes, partners, NGOs, businesses, and communities

• Provide updates on global policies related to TB/HIV management, monitoring and evaluation and to examine developments in local operational research and TB in migrants

• Breakout session to discuss best practices, identify constraints, and possible solutions to expand TB/HIV scale-up to inform action points for national operational plans on TB/HIV

• Develop a framework for country specific priorities to accelerate the implementation of TB/HIV activities

• Develop and strengthen partnerships and increase funding for TB/HIV activities

HIV/AIDS in the Asia Pacific Region

Second highest HIV burden in the world

Estimated 4.9 million people living with HIV/AIDS

>95% burden borne by 9 low and middle-income countries

High HIV Burden Countries in Asia PacificCambodia, China, India, Indonesia, Myanmar, Nepal, Papua New Guinea, Thailand, Vietnam



HIV prevalence in new TB cases HIV prevalence in new TB cases (2007)(2007)

0

4

8

12

16

20

Mo

ng

oli

a

Ph

ilip

pin

es

Jap

an

Repu

bli

c o

f K

ore

a

New

Zeala

nd

Ch

ina

Fij

i

Au

stra

lia

Lao

Peo

ple

's D

em

ocra

tic

Repu

bli

c

Sin

gap

ore

Cam

bo

dia

Vie

t N

am

Mala

ysi

a

Pap

ua N

ew

Gu

inea

HIV

pre

vale

nce (

%)

HBC

Source: TB Control in the WPR 2009 Report



Estimated morbidity and mortality due Estimated morbidity and mortality due to TB/HIV co-infection in the Western to TB/HIV co-infection in the Western

PacificPacificEstimated TB/HIV burden in the Western Pacific

(selected countries)

51,483

24,705

12,052

5,560

4,433

2,930

874

295

14,503

6,774

3,101

1,843

1,296

1,049

271

99

0 10,000 20,000 30,000 40,000 50,000

WPR Total

China

Viet Nam

Cambodia

Malaysia

Papua New Guinea

Philippines

Lao PDR

Number

Number of TB/HIV deaths

Number of TB/HIV cases

Source: Global Tuberculosis Control 2009, WHO, Geneva

HIV seroprevalence among TB casesCountry Estimated HIV

seroprevalence among incident TB cases

Country Estimated HIV seroprevalence among incident TB cases

Bangladesh < 0.05 % Myanmar 10.9%

Bhutan Not available Nepal 2.4%

DPR Korea Not applicable Sri Lanka 0.2%

India ~4- 5% Thailand 13-24%

Indonesia 2% -15% (Papua) Timor-Leste <100 cases of HIV reported/yr

Maldives <5 cases of HIV reported/yr

Source: Tuberculosis Control in the South-East Asia Region, WHO/SEARO, New Delhi, March 2009

ART Scale-up in the Asia Pacific Region: 2003-2008

0

100,000

200,000

300,000

400,000

500,000

600,000

2003 2004 2005 2006 2007 2008

Year

Nu

mb

er o

f P

erso

ns

Rec

eivi

ng

AR

T

ART Services in the Asia Pacific Region, 2008

Country Number HIV-Infected (% Adult Prevalence)

Year ART Program Started

Currently Receiving ART

Cambodia 61,400 (0.90%) 2001 31,999

China 700,000 (0.05%) 2002 48,254

India 2,300,000 (0.36%) 2004 199,237

Indonesia 270,000 (0.20%) 2005 10,616

Myanmar 240,000 (0.67%) 2005 15,191

Nepal 70,000 (0.42%) 2004 2,536

PNG 60,000 (1.6%) 2004 5,195

Thailand 530,000 (1.4%) 2000 166,747

Vietnam 280,000 (0.53%) 2005 27,059



Mekong Meeting 2004Mekong Meeting 2004RationaleRationale

• HIV fuels TB epidemic & threatens TB control

• Limited data on HIV/TB co-infection and low awareness

• Lack of collaboration between NTP and NAP

• ART scale up (3by5) and role of NTP



Outcome of Mekong Outcome of Mekong ConferenceConference

• 127 participants from 11 countries, 5 day meeting

• Experiences, lessons learned shared: 6 focus countries + partner organizations

• WHO WPRO TB/HIV framework discussed

• Country action plans developed & presented (Cambodia, China, Laos, Myanmar, Thailand, Viet Nam) pilot phase



First First Regional Regional TB-HIV TB-HIV

FrameworFramework k

20042004



A revised A revised framework framework in 2008 to in 2008 to address address

TB-HIV co-TB-HIV co-infection infection

in the Western in the Western Pacific RegionPacific Region

WHO Policy on TB/HIV

+ the “4th I”“Integrated case management”

+ D. Systems strengthening• Establish regular interaction• Resource mobilization • Capacity building• Involve communities, NGOs

Strategy for TB-HIV in the SEA

Region

3 I’s



Policies and Services on TB/HIV in Policies and Services on TB/HIV in 20082008

Country Services available to screen TB for

PLHA

IPT for PLHA (policy-

guidelines)

IPT as part of HIV care

Infection control policy for TB in health facilities

Brunei Darussalam no no no yes

Cambodia yes no no yes

China yes no yes

Fiji yes no no

Lao PDR yes no no yes

Malaysia yes no no yes

Mongolia yes no no yes

Papua New Guinea yes yes yes yes

Philippines yes no yes yes

Singapore yes

Viet Nam yes no no yes

Source: Universal Access Progress Report 2007 and 2008.WHO, UNAUIDS, UNICEF



HIV/TB collaborative activities 2007-2008 HIV/TB collaborative activities 2007-2008 in WPR countriesin WPR countries

CountryNo. (%) HIV+ incident TB cases that received treatment for TB

and HIV

No. (%) newly-enrolled in HIV care given isoniazid preventive

therapy (IPT)

No. (%) of those enrolled in HIV care who had TB status assessed and recorded during

their last visit

2007 2008 2007 2008 2007 2008

Cambodia NA NA NA NA NA (85.7 in 1 site)

China NA NA NA NA NA NA

Fiji 1 NA 0 2 (100) 9 11 (14)

Laos 453 293 NA NA 131 (71.6) NA

Malaysia 72 (33.5) 30 NA NA 2002 (89.3) 1958 (88.0)

Mongolia NA 0 0 0 (0) 4 (12.5) 10 (26.0)

Philippines 9 (49.3) 129 (46.0) NA NA NA NA

PNG 320 555 (8.0) 215 (29.8) 47 (2) 870 (38.7) 1487 (67.0)

Viet Nam NA NA NA NA NA NA

Source: Universal Access Progress Reports 2007 and 2008. WHO, UNAIDS, UNICEF



Reported TB/HIV data Reported TB/HIV data (2007)(2007)

Source: Global TB Control 2009, WHO Geneva

All notified

TB cases

# of TB cases tested

for HIV

Of which tested +ve

for HIV

Of HIV +ve, # of

cases on CPT

Of HIV +ve, # of

cases on ARV

China1,045,93

934,557 (3.3%)

1,187 (3.4%)

679 519

Vietnam 98,344 14,377 (15%) 627 (4.4%) NA NA

Cambodia 36,495 14,245 (39%)2,922 (21%)

1,101 610

Malaysia 16,918 10,082 (60%)1,629 (16%)

NA NA

Lao PDR 4,010 424 (11%) 155 (37%) 149 75

Intensified Case Finding – Screening for TB at ICTCs India, 2005-2008

23

95

0 60

51

2

13

21

46

18

95

30

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

2005 2006 2007 2008

Nu

mb

er

HIV positive HIV negative Total

> 8 fold increase in referrals

Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies

0

5,000

10,000

15,000

20,000

25,000

30,000

2005 2006 2007 2008

Nu

mb

er o

f T

B c

ases

am

on

g IC

TC

ref

erra

ls

> 7 fold increase


TB Cases Detected through ICF: India 2005–2008

% n

ewly

det

ecte

d P

HA

sIntensified TB finding among newly detected

PLHIV in Thailand, 2006-8

8189

93

812 14

0

10

20

30

40

50

60

70

80

90

100

2549 (2006) 2550 (2007) 2551 (2008)

Target ≥ 90

TB screening

Known HIV positive TBPatients

Source: Bureau of Tuberculosis Control, Dept of Disease Control, MopH Thailand, July 2009

TB patients Newly HIV Tested: India2005-2008

29488

59654

91807

125756

11870 (9%)

10426(11%)

8785(15%)

6411(21%)

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

2005 2006 2007 2008 (upto Oct)

Nu

mb

er

No.of TB pts HIV tested No. detected HIV infected

> 4 fold increase


IPT

Not policy in any country

Being piloted in Myanmar and Thailand

Commonly heard concerns:

It is difficult to rule out active TB; so we may end up giving monotherapy

INH resistance is high; IPT could further magnify INH resistance.

Managing adherence to IPT is too complicated and would be costly

Not so effective—and IPT efficacy wanes with time



MekongBali-Observations

Dramatic shift in perceptions on TB/HIV

• HIV programmes in Asia– begin to implement TB ICF– explore IPT as an extension of ICF for those who are well– recognize IC in HIV care settings requires urgent action– build TB into funding proposals, routine activities, M&E

• TB programmes in Asia– view TB/HIV as core activity– include HIV data in routine recording/reporting– find and refer co-infected patients to HIV care & ART

• Both programmes– committed to working together to mitigate dual burden of

TB/HIV, and strengthen health systems along the way



Bali-Highlights and Conclusions

• Good progress since Mekong Conference. High level uptake of PITC, ICF varied, low IPT and IC, 4th I promising

• Collaboration between NAP and NTP improving, though still insufficient in many countries. Structural corrections?

• Multi-sectoral developments needed (private sector, Min. of Labour, Unions, Civil society, NGO’s, Faith based organizations)



Bali-Conclusions 2• Communities involvement and participation:

great potential PLHA rights based approach, balance heavy medical approach of TB

• Encouraging examples of extension of TB services into Harm Reduction services for IDU. Issues of stigma

• Strengthen monitoring functions better and more reliable data needed by programmes, to sustain advocacy and document achievements.

• Document good experiences through case studies



Bali-Conclusions 3

• Engage/include TB services into “linked responses” (HIV/STI/RSH services)

• Concerns about women’s vulnerability and social exclusion. Include TB services for HIV+ mothers through PMTCT

• Slow progress of IC efforts. Risk of fragmentation, but opportunity to integrate IC into HSS and submit proposals for funding



Bali-Conclusions last• Urgent need to improve communication,

especially in support of ICF (TB Diagnostic algorithm), and IPT addressing decision makers, professional bodies-experts, and beneficiaries

• Investment on operational research, in developing better tools for ICF (diagnostic algorithm) and IPT (cost effectiveness and benefit analysis)

• Momentum for funding, especially for TB



• HIV and TB Programmes in Asia Pacific Countries

• Nani Nair, StopTB SEARO

• Padmini Srikantiah, HIV SEARO

• Puneet Dewan, StopTB SEARO

• Pieter van Maaren, StopTB WPRO

• Katsunori Osuga, StopTB WPRO

• Fabio Mesquita, HSI WPRO

• Teodi Wi, HIS WPRO

• Nguyen Thuy, HSI WPRO

• Yu Dongbao, HSI WPRO

AcknowledgmentsAcknowledgments

world health organization western pacific region from mekong to bali: scale up of hiv/tb...

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