Jintana Ngamvithayapong-Yanai, Ph.D.

On behalf of TB/HIV Working Group, the Asia-Pacific

The 9th International Congress on AIDS in Asia and the Pacific (ICAAP)10 August 2009: Plenary 2

The Scaling-up of TB/HIV Collaborative Activities in the

Asia-Pacific

Health System Strengthening and Sustaining the Response

From Mekhong 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

OutlineOutline

• Why TB? Why TB/HIV?

• WHO’s TB/HIV Policy

• TB and TB/HIV Situation

• Progress in implementing TB/HIV collaborative activities in Asia-Pacific

• Patient and community contributing to TB/HIV prevention and care

•What next for TB/HIV in Asia-Pacific?

Abbreviations ARV = Antiretroviral drugs

CPT = Co-trimoxazole preventive

therapy

PLHIV = People Living with HIV

3 I (three I) = Intensified TB Case Finding (ICF)

Isoniazid Preventive therapy for

TB (IPT)

TB Infection Control

Unfortunately, my daughter died after TB was cured because poor patients could not pay for anti-retroviral drugs. But now TB/HIV patients in my community can survive, they can live with their family and can feed the family. I miss my daughter….

I miss my daughter…

RIT-JATA and TB/HIV Research Foundation, Thailand

TB…one of the oldest diseases (>4,000 years)

RIT-JATA and TB/HIV Research Foundation, Thailand

In the old days TB was the disease of VIP

Chopin, Pianist, composer

Nelson Mandela, former-president, South Africa

Emperor Akihito

Japan

RIT-JATA and TB/HIV Research Foundation, Thailand

4

22 countries with high TB burden in the world.Asia-Pacific account for 54% of global TB cases

(WHO, 2008)

Burden ranking 1. India 2. China 3. Indonesia 4. Nigeria 5. Bangladesh 6. Nigeria 7. South Africa 8. Ethiopia 9. Philippines10. Kenya 11. Democratic Republic of Congo 12. Rusian Federation 13. Viet Nam 14. Tanzania 15. Brazil • Uganda 1. Thailand 2. Mozambigue 3. Myanmar 4. Zimbabwe 5. Cambodia 6. Afghanistan

RIT-JATA and TB/HIV Research Foundation, Thailand

TB is transmitted by the tuberculosis patients who do not receive treatment

(when coughing, sneezing, spitting, speaking)

-TB/HIV Research Project(RIT JATA -TB/HIV Research Project(RIT JATA))

Why worry about TB?

TB/HIV Research Project (RIT-JATA)RIT-JATA and TB/HIV Research Foundation, Thailand

Most TB is curable even in PLHIV 4 drugs for 6-8 months

Isoniazid, Rifampicin, Pyrazinamide, Ethambutol.

http://www.textbookofbacteriology.net/tuberculosis_3.html

Why TB and HIV?

• HIV is the most powerful known risk factor for reactivating latent TB infections into TB diseases

• TB is the leading cause of death in PLHIV• About one-third of PLHIV are infected with TB

Not TB infected

Latent TB infection

Active TB

(disease)

HIV infection (20-30 times risk)

RIT-JATA and TB/HIV Research Foundation, Thailand

WHO-2004 TB/HIV Activities

Collaboration of TB and AIDS programme

Persons having TB

HIV counseling and testing

TB with HIV TB without HIV

-TB treatment - TB treatment

-CPT - HIV prevention

-ARV

-HIV prevention

Persons living with HIV

Screening for TB

Yes No

-TB treatment - IPT

TB infection control

RIT-JATA and TB/HIV Research Foundation, Thailand

What will happen?

-A TB patient is waiting in the crowded setting for 3 hours especially in HIV or ARV clinic

risk of TB transmission to other patients and health workers

Photo credit: Dr.Supalert Natesuwan, Chiang Rai Hospital, Thailand

No estimate

0–4

20–49

>= 50

5–19

HIV prevalence in TB cases, (%)

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2009. All rights reserved

HIV prevalence among TB cases, 2007

Globally in 20071.4 million TB cases in PLHIV450,000 TB/HIV deaths

From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia-

Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia

No reported activity

< 15%

15 to 50%

51 to 75%

More than 75%

Proportion of TB patients tested for HIV

Key

2005

1.9%

Progress of HIV testing for notified TB patients Asia Pacific (47)

2006

2007

0.3%

6.0%

3.7%

200418

22

27

29

0.2 of 3.1 million notified TB patients

were tested in ASIA PACIFIC REGION in 2007

ASIA PACIFIC 2007 Proportion of TB patients with known HIV status

Country Proportion TB

patients with HIV status know 2007

Thailand 69% 8% 49%Japan 64% 0.1% 60%Malaysia 60% 2% 37%Australia 41% 0.02% 37%Cambodia 39% 3% 53%Viet Nam 15% 6% 5%Lao PDR 11% 0.15% 53%Sri Lanka 6% 0.005% 21%India 5% 52% 9%China 3% 13% 5%Myanmar 2% 5% 10%Papua New Guinea 1% 1% 1%Indonesia 0.10% 8.1% 1%Philippines 0.03% 0.4% 0%

Source: WHO. Tuberculosis Report 2009.

HIV testing and treatment, 2007

Region TB patients tested for HIV, thousands (%)

HIV prevalence in TB patients

% of identified TB patients on CPT

% of identified TB patients on ART

Southeast Asia

122 (5.5%) 15% 37% 17%

Western

Pacific Region

95 (6.6%) 7% 45% 28%

Source: WHO. Tuberculosis Report 2009.

% 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

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

Policies and Services on TB/HIV in 2008Policies and Services on TB/HIV in 2008

Country Services available to screen TB for PLHIV

INH prophylaxis for PLHIV

IPT as part of HIV care

Infection control policy for TB in 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: Country reports for Universal Access Progress Report 2007 and 2008. Data of 2008 are provisional.

60.4%

55.9%51.6%

29.4%

4.8%2.3%

8.2%

18.0%

48.3%

28.1%28.3%29.1%

41.3%

47.7%

34.3%

54.5% 52.4%

37.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2000 2001 2002 2003 2004 2005 2006 2007 2008

DeathDeath

ARV of TB patientsARV of TB patients

Trend of death rate in HIV positive TB patients and the coverage of ART in Chiang Rai province, Thailand

(Source: TB/HIV Research Project, RIT-JATA, 2009)

TB/HIV 774 769 674 733 749 693 543 508 442

Isoniazid reduces risk of TB in HIV-positive: PLHIV cohort in Isoniazid reduces risk of TB in HIV-positive: PLHIV cohort in Chiang Rai Province, Chiang Rai Province, Preliminary analysis: observation time from Preliminary analysis: observation time from September 2002 to December 2008September 2002 to December 2008

393900

1,41,48383

NN

1111

116644

TB TB

--

2.32.30-0-8.88.844

95 % 95 % conficonfidencdenc

e e interintervalval

11

4.24.288

RelatiRelative ve

risk risk RatioRatio(crud(crud

e)e)

--

<0.<0.000011

P P valuvalu

ee

373799

1,31,31919

Non Non TBTB

IPTIPT

No No IPTIPT

Source: TB/HIV Research Project (RIT-JATA)Source: TB/HIV Research Project (RIT-JATA)

Two diseases…many pill burdens

Photo credit: Dr,Somsak Akkasil, CDC 7, Ubon, Thailand

mortar-pestle

chicken’s crow

How do poor patients adhere to TB and ARV treatment?

Temple’s bellTemple’s bell

RIT-JATA and TB/HIV Research Foundation, Thailand

Once in my life…someone

called me“brother”

RIT-JATA and TB/HIV Research Foundation, Thailand Doctor who think TB/HIV and involved patient network for TB/HIV care

Patient network

Next stepsNext steps

TB and HIV communities need to collaborate more closely

• To stop people living with HIV from dying of TB

• To reach the most vulnerable populations

(IDU, prisoners, migrant populations)

• To strengthen the systems that support health

•Laboratory strengthening, drug procurement

•Engaging communities in the response

•Engaging other sectors – justice, labour..