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TB and HIV Management in High HIV Prevalence Settings: the Policy Perspective. Kevin M. De Cock Center for Global Health Centers for Disease Control and Prevention. Integration Blues. Why integrate? Improved health outcomes Better service performance Increased efficiency Cost savings - PowerPoint PPT Presentation
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TB and HIV Management in High HIV Prevalence Settings: the Policy Perspective
Kevin M. De CockCenter for Global Health
Centers for Disease Control and Prevention
Integration Blues
Why integrate?• Improved health outcomes• Better service performance• Increased efficiency• Cost savings• Patient/client convenience
Potential adverse effects:• Erosion of technical quality• Loss of accountability• Lowering of morale• Nosocomial infection
Two, four, six, eight,Time to go and integrate….
Tom Lehrer
Policy, Regulations and Guidelines
• PolicyA course of action (or inaction) usually taken by authorities with regard to a particular set of issues
The “what” and “why”
• Regulations and GuidelinesTools to implement a particular policy choice
The “how”, “when” and “where”
Cases in millions
02468
10
19901994
19982002
2006
LargestImpact
SmallestImpact
Factors that affect health
ExamplesCondom use
Tuberculosis treatment
Male circumcision
Socioeconomic Factors
Changing the Contextto make individuals’ default decisions healthy
Long-lasting Protective Interventions
ClinicalInterventions
Counseling & Education
Poverty, education, housing, inequality
Functioning public health system, universal access
Policy and the Evidence Base
Evidence• Science should drive public
health policy• “Evidence-based” or
“evidence-informed”?• “Everyone is entitled to his
own opinion, but not to his own data”
Values • Human rights • Social justice • Dignity• Ethics and morals• Politics• “The duty to protect”
6 GH Friedland, MD
Which model of collaboration ?
TB HIV/AIDS
TB AIDS TB/AIDS
SeparateTB/ HIV patients referral
FullOne stop service for TB-HIV co-infected
TB AIDS
PartialSome mixing
7 GH Friedland, MD
Current and Optimal TB and HIV Program Paradigms
Current TB and HIV Programs Paradigm
Optimal TB and HIV Programs Paradigm
National TB Program
HIV Services
VCTOI Px
AntiretroviralsAdherence
Support
NationalHIV Program
NationalHIV Program
CommunicationCollaboration
TB Services
Sputum collectionDOT
Treatment SupportContact TracingLTBI Treatment
TB Services
Sputum collectionDOT
Treatment SupportContact TracingLTBI Treatment
HIV Services
PITCOI Px
AntiretroviralsAdherence
Support
National TB Program
Communication and
Collaboration
8
From DOTS to the Stop TB Strategy• High quality DOTS
expansion• TB/HIV, MDR-TB,
vulnerable populations• Health systems
strengthening, primary health care
• Engage all care providers• Empower TB patients,
communities through partnerships
• Research
8
9
Policy and Practice
TB Treatment Outcome• Cured• Treatment completed• Died• Treatment failure• Transferred out• Default
A. Establish NTP-NACP collaborative mechanisms Set up coordinating bodies for effective TB/HIV activities
at all levels Conduct surveillance of HIV prevalence among TB cases Carry out joint TB/HIV planning Monitor and evaluate collaborative TB/HIV activities
B. Decrease burden of TB among PLHIV (the "Three I's") Establish intensified TB case finding Introduce INH preventive therapy Ensure TB infection control in health care and congregate
settings
C. Decrease burden of HIV among TB patients Provide HIV testing and counselling Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy Ensure HIV/AIDS care and support Introduce ARVs
World Health Organization
Policy on collaborative TB/HIV activities A WHO Document, 2004
Lancet 2006; 368: 1575-80
TB Infection Control – 10 Steps• Involve community• Develop IC plan• Safe sputum collection• Cough hygiene• Triage TB suspects• Rapid diagnosis and treatment• Improve room ventilation• Protect health care workers• Capacity building• Monitor IC practices
Science 2010; 328:856
Game Changers
• Discontinuous, radical innovations completely changing the way something is done, thought about, or made. Examples:
- Cell phones - HIV/AIDS- Laptop computers - Antiretrovirals- Internet - PEPFAR- 9/11
Antiretroviral Therapy for HIV Prevention
• Transmission occurs only from HIV+ persons
• Viral load is strongest risk factor for transmission
• ART can lower viral load to undetectable levels
• PMTCT offers proof of concept of reduced transmission with ART
• Discordant couple studies are supportive
Discordant Couple StudiesReynolds S et al. 16th CROI, Montreal, Feb 2009 Abs. 52a
Marcelin A et al. 16th CROI, Montreal, Feb 2009 Abs. 51
Donnell D et al. Lancet 2010;375:2092-8
Antiretroviral therapy for HIV prevention
• Mathematical model of universal HIV testing annually with immediate ART for HIV+ in southern African epidemic
• 95% reduction in HIV incidence in 10 years
• Prevalence <1% in medium term
• Major reduction in mortality
• Cost-saving in medium termLancet 2009;373:48-57.
Trial of 6 vs 36 mos of isoniazid preventive therapy, Botswana
(Samandari T et al, 2009)
TB/HIV in High HIV Prevalence Settings
What will it take?• Evidence and data• Innovative and clear thinking• Judgment - balancing risk and “reckless
caution”• Leadership• Policy, linked to research, implementation and
advocacy