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TB/HIV UpdateCentral TB Division
Estimated HIV prevalence in new TB cases, 2008
National estimate – 4.85% of Incident TB cases are HIV positive
Proportion of Registered TB patients who are HIV+, 1q10
<1%1%-4.9%5%-9.9%
>10%
Highly Variable!!
RNTCP: HIV status among TB patients registered for DOTS1Q-2Q 2009 Karnataka State
District
Total TB patients registered for DOTS
No. known to be tested for HIV (%)
Of the number tested for HIV, no. known to be HIV infected (%)
Minimum % HIV positive among registered TB patients
BAGALKOT 1114 913 82% 423 46% 38%
BELGAUM 2544 1812 71% 493 27% 19%
BIJAPUR 1135 790 70% 340 43% 30%
DHARWAD 931 612 66% 116 19% 12%
GADAG 530 332 63% 54 16% 10%
HAVERI 750 577 77% 67 12% 9%
UTTARA_KANNADA 646 359 56% 54 15% 8%
BIDAR 856 649 76% 66 10% 8%
BELLARY 1528 1075 70% 133 12% 9%
GULBARGA 1922 959 50% 152 16% 8%
KOPPAL 877 757 86% 134 18% 15%
RAICHUR 1456 1193 82% 187 16% 13%
KARNATAKA 34165 24246 71% 3977 16% 12%Source: Central TB Division, 2009
Treatment outcomes for HIV-positive and HIV-negative TB patients, 2006 cohort
The numbers under the bars are the numbers of patients included in the cohort
Treatment Outcomes of HIV positive and HIV negative TB patients, 4q08
0%
20%
40%
60%
80%
100%
HIV+ HIV- HIV+ HIV-
Transfer Out
Default
Failure
Death
Success
NSP TB Patients All TB Patients
(N=2034) (N=141304) (N=5422) (N=345661)
Lawn et al, CROI 2007
After TB diagnosis, delayed ART initiation associated with higher death rates
Mortality rate** (95% CI)
Early arm
8.28
(6.42 – 10.69)
Late arm
13.77 (11.20 – 16.93)
** per 100 person-years
CAMELIA STUDY
SIGNIFICANT REDUCTION OF MORTALITY IN THE EARLY ARM
ANRS 1295/12160 - CIPRA KH001/10425 ANRS 1295/12160 - CIPRA KH001/10425 studystudy
0.60
0.65
0.70
0.75
0.80
0.85
0.90
0.95
1.00
Pro
bab
ility
of su
rviv
al (
%)
0 50 100 150 200 250Time from TB treatment initiation (weeks)
Early arm Late arm
Mortality rate** (95% CI)
INTEGRATED
5.4
(3.5-7.9)
SEQUENTIAL
12.1 (8.0-17.7)
** per 100 person-years
Karim et al, Durban, SOUTH AFRICA
EARLY ART INITIATION SIGNIFICANTLYREDUCES MORTALITY
“Nationally, RNTCP should be able to reverse the increases in TB burden due to HIV but, to ensure that TB mortality is reduced by 50% or more by 2015, HIV-infected TB patients should be provided with antiretroviral therapy in addition to the recommended treatmentfor TB.”
Summary: TB-HIV Interaction in India• India has the highest burden of TB, and a high
burden of HIV in the world• Most TB is among persons without HIV;
magnitude variable• HIV may slow down TB control efforts in India
– Particularly efforts to reduce mortality
• Enormous need for improved TB-HIV programme collaboration
Response to TB-HIV
The STOP TB Strategy, 2009 Updated language underlined
2006/rev. 2009
1. Pursue high-quality DOTS expansion and enhancementa. Secure political commitment, with adequate and sustained financing b. Ensure early case detection, and diagnosis through quality-assured bacteriologyc. Provide standardised treatment with supervision, and patient supportd. Ensure effective drug supply and management e. Monitor and evaluate performance and impact
2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations
a. “Scale–up” collaborative TB/HIV activitiesb. Scale-up prevention and management of multidrug-resistant TB (MDR-TB)c. Address the needs of TB contacts, and poor and vulnerable populations
3. Contribute to health system strengthening based on primary health care a. Help improve health policies, human resources development, financing, supplies, service
delivery and informationb. Strengthen infection control in health services, other congregate settings and householdsc. Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL) d. Adapt approaches from other fields and sectors, and foster action on the social determinants
of health4. Engage all care providers
a. Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches
b. Promote use of the International Standards for Tuberculosis Care (ISTC)5. Empower people with TB, and communities through partnership
a. Pursue advocacy, communication and social mobilizationb. Foster community participation in TB care, prevention and health promotionc. Promote use of the Patients' Charter for Tuberculosis Care
6. Enable and promote researcha. Conduct programme-based operational research, and introduce new tools into practiceb. Advocate for and participate in research to develop new diagnostics, drugs and vaccines
Evolution of TB-HIV collaborative activities in India
• 2001–First TBHIV “Joint Action Plan” developed; Basic activities in 6 high-HIV burden states
• 2003- Cross referral piloted in MH and initiated in 6 states• 2004–Expanded to 8 additional States• 2005–Joint training modules, surveillance• 2007–Expanded surveillance, CPT/Routine referral pilot, National
Framework for TB/HIV• 2008–National Framework revised, all-India implementation begins
with Intensified package in 9 states
• 2009 – National Framework revised, Intensified package scaled up to include 8 more states
• 2010 – Intensified package launched in 11 states
• Currently 11 states implementing (TN,AP,KA,MH,PD,GA,MZ,MN,NG,GU,DL)• Launched in 7 states (AS,WB,OR,KE,RJ,PN,CH) IN 2009• Rolled out in 11 states in 2010 (HR,UK,HP,JH,CG,TR,ArP,ME,SI,MP,UP)
Intensified TB-HIV package - Nationwide
coverage by 2012
Implementing Launched (2009)Launched (2010)
National TB/HIV Framework 2009…1
All States Intensified Package States
District and State-Level Coordination mechanisms between NACP and RNTCP
Uniform Intensified TB Case Finding at all ICTCs, ART Centres, and Community Care Centres with Line-list
and Standard ReportingTraining in basic TB/HIV
module Additional training on
Intensified TB/HIV Package
National TB/HIV Framework 2009…2All States Intensified Package States
Referral of TB patients for HIV-testing based on HIV risk
factors (selective referral)
Routine referral of all TB patients for voluntary HIV-
counselling and testing (ISTC 14)
Linking HIV-infected TB patients to HIV care and
support, including CPT & ART
Addition: Decentralized CPT(ISTC 15)
Core TB/HIV recording and reporting from NACO MIS and
RNTCP (PMR)
Addition: Expanded TB/HIV recording and reporting(Shared Confidentiality)
All TBHIV Training Modules revised
A new “TBHIV module for ART centre staff” created
• Intensified TB case finding at ART centres with standardised R&R
• Rifabutin use among HIV-infected TB patients receiving Second line ART or Alternative First line ART (containing Protease Inhibitors) approved
• Infection control guidelines for ART centre setting included
• ART in HIV-infected TB patients – regimen, timing of initiation, special situations clarified
International & National Guidelines for ART in HIV-infected TB patients
WHO (2009) NACO (2009)
Who is eligible? ALL, regardless of CD4 (strong recommendation, low
quality of evidence)
ALL Stage 4 (EP-TB, disseminated, miliary)
CD4<350 (Pulm)
When to start? Start TB treatment first, followed by ART as soon as possible after starting
TB treatment.(strong rec, moderate evidence)
Start TB treatment first, followed by ART as soon as possible, 2 weeks after starting TB
treatment
What to start? Use EFV as the NNRTI in patients starting ART
while on TB treatment.
Use EFV as the NNRTI in all TB patients
receiving ART
TB/HIV Performance
66%62%60%
34%44%
54%
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
4q08 1q09 2q09 3q09 4q09 1q10
Num
ber o
f Reg
iste
red
TB P
atien
ts Unknown HIV status
Known HIV status
Trends in Number (%) of registered TB patients with known HIV status, 4q08-1q10
Proportion of TB patients with known HIV status, States, 1q10
87%83% 80% 81% 78%
66% 67%
52%57%
29%37%
26%
13%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goa KA AP TN PD India GU DL MH MN NG MZ AS
Proportion of TB patients with known HIV Status, 1q10
<49.9%50%-79.9%>80%
Proportion of Registered TB patients who are HIV+, 1q10
<1%1%-4.9%5%-9.9%
>10%
Number (%) of HIV+ TB patients receiving CPT during TB treatment, 4q08-2q09
By quarter of TB registration85%
74%68%
0100020003000400050006000700080009000
4q08 1q09 2q090%10%20%30%40%50%60%70%80%90%
Number of HIV+TB patients receiving CPT % of HIV+TB patients receiving CPT
Number (%) of HIV+ TB patients receiving ART during TB treatment, 4q08-2q09
By quarter of TB registration47%43%
41%
0500
100015002000250030003500400045005000
4q08 1q09 2q090%
10%
20%
30%
40%
50%
Number of HIV+TB patients receiving ART % of HIV+TB patients receiving ART
Trends in Number of TB suspects referred from ICTC to RNTCP 2006–2009
3.5%3.9%
5.2%6.1%
0
50000
100000
150000
200000
250000
300000
350000
2006 2007 2008 20090.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
No. TB suspects referred % of ICTC Clients referred
Trends in TB case detection from ICTC to RNTCP referrals, 2006–2009 (till September)
77% 81% 82% 84%
05000
10000150002000025000300003500040000
2006 2007 2008 20090%10%20%30%40%50%60%70%80%90%
No. TB cases diagnosed from ICTC referrals % of TB cases put on DOTS
Next Steps – 2010-15• Intensified TB/HIV package - Nationwide coverage by 2012
– Provider-initiated HIV testing for all TB patients– Immediate and accountable linkage of HIV-infected TB patients to
NACP for HIV care and treatment• Intensified TB case finding and reporting – Consolidation in
all HIV care settings• Completed clinical and operational research on IPT for
TB/HIV with policy decisions• Implementation of airborne infection control measures• HIV Surveillance among TB suspects at some sentinel sites• RCT among HIV-infected TB patients comparing daily v/s
intermittent regimens
Role of Medical College in TB/HIV collaborative activities
• Academics– Frequent updates / CMEs for faculty and students– Demonstration of TB/HIV care settings to students
• Patient Care– Implementation of ICF and IC at ICTCs and ART centres– Implementation of PITC for TB patients and Early ART
initiation for HIV-infected TB patients• Research
– Operational Research and PG Thesis– Funding available under RNTCP
• Quality Assurance– Part of RNTCP Internal Evaluations and Joint TB/HIV Visits– Peer Pressure on professional colleagues to follow ISTC
Thanks..
A dedicated webpage for TB-HIV