TB Activist Toolkit - TB/HIV Epidemiology and Impact [Facilitators Notes]

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%C=:DE=FD'*GD6HF'BCHI8'0F96F='%HH9J6D !"#$%&'"()*+%,'-!.'"/'"%'"()01%*2%3 "2%1045+%"02 The aim of the TB/HIV Activists’ Toolkit is to provide activists with fundamental information about tuberculosis (TB) and TB/HIV in order to strengthen their science, research, and policy literacy and advocacy. We hope that activists will use this information to inform their advocacy and to develop community education materials and sessions on TB and TB/HIV. The facilitator notes and slide set are teaching tools that can be used as is or modified to suit your needs and audience. We estimate that it will take 60 minutes to complete this module using the accompanying slide set. The module is broken up into sections that can be taught as separate units or in one workshop. Time estimates have been included for each section of the module for your reference, but will vary based on the facilitator’s comfort with and the participants’ understanding of the material. Please use the time allotments as a planning guide rather than a rule. The information in the facilitator notes is organized into five main categories: 1. Fundamental information provides further explanation of the information on the slides and slide notes, and is what we consider to be “need-to-know� information. 2. Teaching points/exercises are optional and are meant to provide an opportunity to reinforce information and/or stimulate discussion. 3. Review revisits key points of each section and provide an opportunity for clarification or further explanation. 4. Definitions provide explanation of commonly used and/or key terms. These terms are italicized in the main text. 5. “Nice to know� information is not considered necessary or fundamental to understanding basic concepts of this module but is “nice to know.� Please be careful before citing this information in a workshop, as participants who are new to TB and TB/HIV may get overwhelmed by too much information. These facilitator notes are meant to be used as a guide for and explanation to the slide set. However, facilitators should feel free to develop their own slide sets or teaching tools using the notes and/or modifying the slides depending on your needs. Introduction to module (5 minutes)

!"46789:;'796<='>' (045?@'A,'%&$!"#'@)"4@("0?0B.'*24'"()*+% The goal of this module is to provide activists with an understanding of the epidemiology of TB and TB/HIV, how the two diseases impact one another, and the need to advocate for TB/HIV collaboration. At the end of this module participants will

s BE FAMILIAR WITH THE GLOBAL AND REGIONAL BURDEN OF 4" AND 4" ()6 s BE ABLE TO EXPLAIN HOW 4" AND ()6 IMPACT ONE ANOTHER s BE ABLE TO DESCRIBE THE RECOMMENDED 4" ()6 COLLABORATIVE ACTIVITIES s BE ABLE TO IDENTIFY SOME OF THE MOST PRESSING ADVOCACY ISSUES FOR 4" ()6 collaboration

!"46789:;'796<='A' Review topics to be covered

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S E C T I O N 1 Global and Regional Statistics (slides 3–16; 30 minutes)

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NICE TO KNOW The World Health Organization (WHO) is an agency of the United Nations (UN) that acts as a coordinating body on international public health. For more information on the WHO, go to http://www.who.int/en/. UNAIDS, the Joint United Nations Programme on HIV/AIDS, is a joint venture of the ten UN system organizations involved in the AIDS response to help the world prevent new HIV infections, to give care to people living with HIV, and to mitigate the impact of the epidemic. For more information on UNAIDS, go to http:// www.unaids.org/en/. NICE TO KNOW The annual global TB report provides surveillance data on TB control. Surveillance is the ongoing, systematic collection of health data that are used to guide the development and implementation of public health guidelines, programs, and policies. Surveillance data includes statistics on different health events (e.g., the number of of TB deaths in a year, or the number of new cases of TB) and on health services (e.g., the number of people notified of TB diagnosis, or the number of people put on TB preventative treatment).

!"#$%&#'(')* is the study of factors affecting the health and illness of populations, and serves as the foundation and rationale for interventions made in the interest of public health and preventive medicine. +,-#$%,-% is any new occurrence of disease in a given period of time in a population.

Note to Facilitator : Please be aware that the cited HIV and TB statistics come from repor ts developed by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Wor ld Health Organization (WHO): AIDS Epidemic Update 2 0 0 9 ; G l o b a l Tu b e r c u l o s i s C o n t r o l 2 0 0 9 : E p i d e m i o l o g y , S t r a t e g y , F i n a n c i n g ; a n d G l o b a l Tu b e r c u l o s i s C o n t r o l : A Short Update to the 2009 Report. Links to these reports can be found in the Resources section of this module. Tr a d i t i o n a l l y, t h e W H O h a s p u b l i s h e d t h e G l o b a l T B r e p o r t o n M a r c h 2 4 o f e a c h y e a r. H o w e v e r, t o e n s u r e t h a t t h e repor ts have the most accurate and current data, the WHO has changed its publication cycle and will not be releasing the 2010 report until fall 2010. As a result, the WHO has put out an update to the 2009 report based on data collected from July to September 2009.

!"46789:;'796<='L Despite being curable, tuberculosis (TB) is a major cause of illness and death worldwide, particularly in Asia and Africa. In fact, it is estimated that one-third of world is infected with TB, and worldwide a new infection occurs every second. In 2008: s 4HERE WERE BILLION PREVALENT CASES OF 4" s 4HERE WERE MILLION NEW CASES OF 4" WHICH IS AN INCREASE FROM MILLION IN s /F THESE MILLION NEW 4" ()6 CASESˆTHAT IS PERCENT OF THE MILLION INCIDENT CASESˆWERE AMONG PEOPLE WITH ()6 3EVENTY EIGHT percent of TB/HIV coinfected cases were found in sub-Saharan Africa, and about 13 percent were in Asia, predominately in India. About 25 percent of all HIV deaths were TB-related, which makes TB the largest cause of death among people with HIV. When discussing surveillance data there are some commonly used terms that are important to know. The first is incidence, which refers to all new cases of a disease within a given population during a set period of time. Prevalence refers to the number of existing cases of disease in a given population during a period of time. It may sound like these two words are saying the same thing, but they are not. There is a very important difference: incidence refers to new cases of a disease, while prevalence refers to all cases of a disease. So, prevalence includes all incident cases. Another way to explain this is to imagine a bathtub that is half full. All of the water coming out of the tap into the tub represents the incident (or new) cases and the water in the tub (including the new water) represents the prevalent (or existing) cases.

./%01(%,-% refers to already existing cases of disease in a given period of time in a population and will include incident cases.

So in 2008, there were two billion prevalent cases (water in the tub) of TB, including the 9.4 million incident TB cases (water coming from the tap).

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!"46789:;'796<='M Of the 9.4 million incident (or new) cases of TB in 2008, s HALF A MILLION WERE CONlRMED AS multidrug-resistant TB (MDR-TB) s APPROXIMATELY WERE CONlRMED AS extensively drug-resistant TB (XDR-TB) s MILLION WERE COINFECTED WITH ()6 !)$3 In 2008, of the 2 billion prevalent (or all) cases of TB,

23(4#$/3)5/%6#641,47897:2;<589= refers to TB that is resistant (or not susceptible) to two firstline TB medications, isoniazid and rifampicin. !>4%,6#0%(*7$/3)5/%6#641,47897:?;<589= refers to TB that is resistant (or not susceptible ) to isoniazid and rifampicin as well as any of the fluoroquinolones (considered second-line treatment) and any of the second-line injectables (amikacin, kanamycin, and capreomycin).

s MILLION DIED THIS IS AN INCREASE FROM MILLION IN s APPROXIMATELY PEOPLE WITH -$2 4" DIED s APPROXIMATELY PEOPLE WITH 8$2 4" MORE THAN HALF OF THOSE WITH 8$2 4" DIED s PEOPLE COINFECTED WITH 4" ()6 DIED 4HIS IS AN INCREASE FROM IN AND ACCOUNTS ALMOST ENTIRELY FOR THE INCREASE IN 4" DEATHS FROM TO There will be more on drug resistance later in this module.

!'46789:;'796<='N The WHO divides its member states up into six regions, and each region has a regional office. Surveillance data are also reported regionally:

s s s s s s

!&2/ 3UB 3AHARAN !FRICA COUNTRIES !-2/ 4HE !MERICAS COUNTRIES FROM .ORTH AND 3OUTH %-2/ 4HE %ASTERN -EDITERRANEAN COUNTRIES %52/ %UROPE COUNTRIES 3%!2/ 3OUTHEAST !SIA COUNTRIES 702/ 4HE 7ESTERN 0ACIlC COUNTRIES

)N 3OUTHEAST !SIA ACCOUNTED FOR PERCENT OF ALL NEW 4" CASES with sub-Saharan Africa a close second at 31 percent. Together these two regions accounted for 65% of the global burden of new TB cases. The Western Pacific followed with 21 percent, the Eastern Mediterranean with 6 percent, Europe with 5 percent, and the Americas with 3 percent of all new cases of TB.

!"46789:;'796<='O The WHO has designated 22 countries as high-TB-burden countries because they rank highest in absolute numbers of TB cases. Altogether these countries represent 80 percent of the global burden of TB. The 22 high-TB-burden countries in order of TB burden are: 1. India

9. Philippines

16. Uganda

2. China

10. Democratic Republic of Congo

:IMBABWE

3. South Africa 4. Nigeria 5. Indonesia 6. Bangladesh %THIOPIA 8. Pakistan

11. Russian Federation 12. Vietnam 13. Kenya 14. Brazil 15. United Republic of Tanzania

18. Thailand 19. Mozambique 20. Myanmar 21. Cambodia 22. Afghanistan

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;/3)5636-%"4#@(%789, also referred to as drugsensitive TB, is TB that can be successfully treated and cured by first-line anti-TB treatment. ./#&1/*7$/3)7/%6#641,-% refers to infection with TB that is already drug resistant. A%-',$1/*7:1-B3#/%$=7$/3)7/%6#641,-% refers to drug resistance that develops during treatment due to in adequate treatment and/or poor treatment adherence.

C,4#5897$/3)6 GROUPING

DRUGS (Abbreviation)

Group 1:

isoniazid (H)

First-line oral anti- rifampicin (R) TB drugs ethambutol (E) PYRAZINAMIDE : rifabutin (Rfb) Group 2:

streptomycin (S)

Injectable anti-TB drugs

kanamycin (Km) amikacin (Amk) capreomycin (Cm)

Group 3:

ofloxacin (Ofx)

Fluoroquinolones

levofloxacin (Lfx) moxifloxacin (Mfx)

Group 4: Oral bacteriostatic second-line

ethionamide (Eto) protionamide (Pto) cycloserine (Cs) terizidone (Trd) p-aminosalicylic acid (PAS);

Group 5: Anti-TB drugs with unclear efficacy for MDRTB treatment (not recommended by the WHO for routine use in MDR-TB patients)

clofazimine (Cfz linezolid (Lzd) amoxicillin/ clavulanate (Amx/Clv) thioactezone (Thz) clarithromycin (Clr) imipenem (Ipm))

Source: Adapted from the WHO Guidelines for the Programmatic Management of Drug-Resistant Tuberculosis, Emergency Update 2008.

!"46789:;'796<='P' EXERCISE: ASK PARTICIPANTS TO DEFINE MDR-TB AND XDR-TB .

Multidrug-resistant TB (MDR-TB) is a form of TB that is resistant to isoniazid and rifampicin, two of the most powerful first-line drugs. %XTENSIVELY DRUG RESISTANT 4" 8$2 4" IS RESISTANT TO ISONIAZID AND RIFAMPICIN as well as any of the flouroquinolones (e.g. oxofloxacin, levofloxacin) and at least one of the second-line injectables (amikacin, capreomycin, or kanamycin).

!"46789:;'796<='Q The bacteria responsible for TB becomes resistant when TB patients are not provided with or do not complete a full course of medication; this is known as secondary resistance. Drug-resistant TB, like drug-susceptible TB, can also be transmitted through the air from an infected person to a noninfected person; this is known as primary resistance. How does drug resistance develop? Microbes like MTB and HIV can develop resistance to drugs used to treat them. When people do not complete their full course of treatment, are inconsistent about taking their medications, and/or have not been prescribed the most effective treatment regimen, resistance can develop. When the full course of treatment is not completed, the weakest and most drug-susceptible forms of the microbe are killed off first, leaving room for stronger, or drug-resistant, forms to grow. When people are inconsistent about taking their drugs, the microbe is allowed to grow in the presence of low levels of the drug. This creates an environment that favors mutated forms of the microbe, which are resistant to the drug. Many times people stop taking antibiotics before the end of their course because they begin to feel better. This can mean that the treatment has killed off most of the bacteria, leaving too few to cause symptoms. The remaining bacteria might contain some strains that have developed resistance to the drugs used. These drug resistant strains can then multiply and begin to make these people sick once again. This time, however the treatments that were used the first time will not work, as the new population of bacteria are resistant to them.

!"46789:;'796<='>R The year 2008 saw the highest rates of MDR-TB ever recorded, with an ESTIMATED NEW -$2 4" CASES AND NEW 8$2 4" CASES However, it is important to note that many countries, particularly in subSaharan Africa, did not report any surveillance data on drug resistance due to insufficient laboratory capacity to conduct drug susceptibility testing (DST). Where it is available in many resource-limited settings, DST is only available in one or two labs in a country and on very limited basis; therefore, it is likely that these statistics are a vast underreporting. %ASTERN %UROPE IS THE REGION HARDEST HIT BY -$2 8$2 4" ACCOUNTING FOR SOME OF THE HIGHEST BURDEN COUNTRIES AND CITIES &IFTEEN OF THE COUNTRIES that account for 85% of the world’s MDR-TB cases are located in Eastern Europe. In fact, in some settings in Eastern Europe and the Russian Federation, up to 22% of new TB cases are confirmed as MDR-TB. *For more on drug susceptibility testing, see the TB Diagnostics module.

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+HIFDC6=7'S6DT'GHFU6CE=<'V41W%&'W'ARRO Argentina

Japan

Azerbaijan

Latvia

Australia

NICE TO KNOW In 2006 there was an outbreak of XDR-TB in the Tugela Ferry district of South Africa. Of the 53 people diagnosed, 52 died, most before getting confirmation that they had XDR-TB. All those who were aware of their HIV status were HIV positive, and 51 percent had never been previously treated for TB. After genetically fingerprinting the strains of TB, it was determined that 85 percent of the strains were genetically similar, indicating that much of the TB was transmitted rather than acquired. In fact, a number of the individuals in this group were members of an HIV support group where transmission likely occurred.

border lines for which there may not yet be full agreement. authorities, or concerning the delimitation of its frontiers o whatsoever on the part of the WHO concerning the legal The boundaries and names shown and the designation

Italy

Armenia

Lesotho

Bangladesh

Lithuania

Botswana

Mexico !  WHO 2005. All rights reserved

Brazil

Moldova

Canada Chile

Mozambique Namibia

China, Hong Kong SAR Czech Rep. Ecuador

Nepal

Estonia

Norway

France

Peru

Georgia

Philippines

Germany

Poland

Ireland India

Portugal Rep of Korea

Islamic Rep. of Iran Israel

Russian Fed.

Netherlands

Romania

Slovenia South Africa Spain Swaziland Sweden Thailand UK USA

Ukraine

Vietnam

Based on information from WHO Stop TB Department

5NLIKE -$2 4" 8$2 4" IS RESISTANT TO SECOND AND EVEN THIRD LINE 4" treatments. It can also be highly pathogenic, causing disease rapidly and resulting in a high percentage of deaths. 4HE EMERGENCE OF DRUG RESISTANT 4" BOTH IN ITS -$2 AND 8$2 FORMS threatens people with and without HIV. Because of limited diagnostic capabilities and supplies of second- and third-line TB drugs in many highburden settings, drug-resistant TB remains undiagnosed and improperly treated, resulting in increased morbidity and mortality.

!"46789:;'796<='>A The global prevalence of adults and children with HIV was estimated to be MILLION IN INCLUDING MILLION NEW CASES REPORTED

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*<I9D7':F<'GT69<C=F'=7D6E:D=< DH'\='96]6F^'S6DT'!"#'W'ARRP

North America

1.4Â million

[1.2 – 1.6 million]

Caribbean

Western & Central Europe

Eastern Europe & Central Asia

[710 000 – [710 000 – 970 000]

[1.4 – [1.4 – 1.7 million]

850Â 000

1.5Â million

Middle East & North Africa

240Â 000

[220 000 – 260 000]

Latin America

2.0Â million

[1.8 – [1.8 – 2.2 million]

310Â 000

[250 000 – [250 000 – 380 000]

East Asia

850Â 000

[700 000 – [700 000 – 1.0 million]

South & South­East Asia

3.8Â million

Sub­Saharan Africa

[3.4 – [3.4 – 4.3 million]

[20.8 – [20.8 – 24.1 million]

59Â 000

22.4Â million

Oceania

[51 000 – [51 000 – 68 000]

%HD:9,'KKXL'E6996HF'YK>X>'Z'KMXP'E6996HF[

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Sub-Saharan Africa continues to be the region hardest hit by the HIV/AIDS epidemic, accounting for more than two-thirds of all cases, nearly 85 percent OF ALL ()6 POSITIVE INFANTS AND CHILDREN AND PERCENT OF ALL ()6 DEATHS worldwide. Even in the sub-Saharan region, the epidemic varies significantly country to country. The national HIV prevalence rates range from just over 1 percent to above 15 percent in some countries in the region. The Southern African subregion accounts for 35 percent of all people with HIV and almost one-third of all new infections and AIDS death globally in 2008.

!"46789:;'796<='>L NICE TO KNOW The purpose of this Venn diagram, like many types of graphs, is to illustrate a mathematical relationship between two or more things. In this case, there are two circles, one representing the number of people with HIV and a larger one representing the number of people living with TB. The size of each circle represents the size of this set of people, so the larger circle represents the larger group of people. The cirles are positioned to overlap such that the area of overlap (in this case the in area in the middle) represents the size of the group where these two populations overlap—that is, how many people are living with both HIV and TB. By looking at the size of the three groups—people living with TB, people living with HIV, and people living with both—you can see the relative size or scope of these epidemics.

%T='0]=C9:8'\=DS==F'%&':F<'!"# >>'E6996HF'Y%&':F<'!"#'GHW6FU=GD=<[

%&'6FU=GD6HF A'\6996HF

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Based on data from WHO Stop TB Department

This graphic represents the intersection of the TB and HIV epidemics. It is estimated that one-third of the world’s population (amounting to 2 billion people) is infected with TB; therefore, if there are 33 million people with HIV it is estimated that there are 11 million people who are coinfected. However, due to poor diagnostic capacity and limited HIV testing of TB patients and TB screening of people with HIV, the current numbers being reported to the WHO are likely underestimates of the scale of TB/HIV coinfection.

!"46789:;'796<='>M Tuberculosis is the leading cause of death for people with HIV, accounting for 25 percent all HIV deaths in 2008, yet it is a preventable and treatable disease. HIV is driving the TB epidemic, particularly in sub-Saharan Africa and other high HIV-burden settings. The sub-Saharan African region, particularly SOUTHERN !FRICA IS MOST AFFECTED AND ACCOUNTS FOR PERCENT OF ALL ()6 POSITIVE 4" CASES FOLLOWED BY 3OUTHEAST !SIA MAINLY )NDIA WHICH ACCOUNTS for the largest number of the remaining cases (about 13 percent).

!"46789:;'796<='>N Note that more than half (38 countries) of the 63 high-TB/HIV-burden countries are located in eastern, central, southern, and western Africa.

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REVIEW Q. How many people are infected with TB globally? A. It is estimated that one-third of the world, or two billion people, is infected with TB. Q. What does incidence refer to? A. Incidence refers to all new cases of a disease in a given population during a period of time. There were 9.4 million incident cases of TB in 2008. Q. What does prevalence refer to? A. Prevalence refers to all cases of a disease in a given population during a period of time, and includes incident cases. There were 2 billion prevalent cases of TB in 2008. Q. What is meant when referring to the 22 high-burden countries? A. These are the 22 countries that, based on their absolute numbers of TB cases, represent 80 percent of the global burden of TB. Q. What is MDR-TB? A. Multidrug-resistant TB, which is TB that is resistant to isoniazid and rifampicin. Q. What does primary transmission refer to? A. Primary transmission refers to infection with TB that is already drug resistant. Q. What does secondary transmission refer to? A. Secondary transmission refers to a person acquiring drug resistance due to inadequate or incomplete treatment. Note to facilitator : If par ticipants have difficulty with these questions, return to the slide to reinforce points they have not identified.

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S E C T I O N 2 : TB/HIV Impact (slides 17–20; 20 minutes)

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NICE TO KNOW The “3 by 5” initiative, launched by UNAIDS and the WHO in 2003, was a global target to provide three million people living with HIV/AIDS in low- and middle-income countries with ARVs by the end of 2005. It was a step toward the goal of making universal access to HIV/AIDS prevention and treatment available to all who need them as a human right. The goal was met, but not until the end of 2007. This represents 31 percent of the estimated global need for ARVs, and 45 percent improvement over 2006 figures. For more information go to http://www. who.int/hiv/en/.

D14%,47897#,E%-4#', refers to the period of time when the immune system has been successful in containing TB bacteria and preventing disease. C-4#0%7897$#6%16% refers to the period of time when TB breaks out of latency and causes disease. ./')/%66#0%7"/#&1/*7$#6%16% occurs when the immune system is not able to contain TB bacteria and disease occurs immediately upon infection.

*For more information on TB disease progression, see the TB Basics module.

<%-3//%,4789 is a second episode of TB occurring after the first episode was considered cured.

With the expansion of antiretroviral treatment (ART) programs mainly after the “3 by 5” initiative (see sidebar), and with more people with HIV living longer, the need for addressing TB within HIV care programs has increased. This slide shows the distribution of opportunistic infections (OIs) in the first three months of starting antiretrovirals (ARVs) in more than 30,000 people with HIV in two geographical regions: sub-Saharan Africa and Europe/North America. Both pulmonary TB (TB in the lungs) and extrapulmonary TB (TB outside of the lungs) were the most common presenting illnesses among people starting ARVs in both regions. It is important to note that in resource-limited and industrialized settings, as well as in settings with high or low TB and HIV prevalence, TB is the most common OI among people with HIV; however, more than a quarter of these patients in sub-Saharan Africa developed TB in the first three months of ARV initiation, indicating that the burden is still greater in resource-limited settings.

!"46789:;'796<='>Q TB and HIV work synergistically, with HIV increasing the risk of progression from latent TB infection to active TB disease and TB increasing vulnerability to HIV disease progression. In healthy immune systems, the risk of progressing from latent TB infection (LTBI) to active TB disease lessens significantly two years after initial TB infection, but the risk in immune-compromised individuals may become greater as immune function declines. HIV-positive individuals who are latently infected with TB are between 2 and 10 times more likely to progress to active TB disease are than their HIV-negative counterparts. TB disease progression is associated with higher HIV viral load and lower CD4 T-cell counts. Likewise, a person who is coinfected with TB and HIV is at increased risk for recurrent TB. There are two causes of a recurrence of TB: relapse and

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<%(1"6% occurs when TB bacteria persist after treatment despite apparent cure, and is caused by insufficient bacteriological cure of the first episode of TB. <%#,E%-4#', occurs when a person is reinfected with a different strain of TB.

*For more information on recurrent TB, see the TB Treatment module. A&%1/5,%)14#0%789 refers to a TB case in which the smear microscopy test results indicate that no TB bacteria are present in the sputum sample, but when using further diagnostic tools TB diagnosis is confirmed. !>4/1"3(&',1/*7:!.89= refers to TB outside of the lungs.

*For more on smear-negative and extrapulmonary TB, see the TB Basics and TB Diagnostics modules.

reinfection. It is difficult to differentiate between relapse and reinfection because both occur after apparent cure. In order to determine the cause of TB recurrence, the bacteria of each TB episode would need to be genetically fingerprinted. This type of testing is usually only available in a research setting, and not used in regular clinical practice. The rates of smear-negative and extrapulmonary TB (EPTB) have been increasing in high-HIV-burden countries. People who are coinfected with TB and HIV are more likely to have smear-negative TB (24–61 percent) and EPTB (4–40 percent) than are HIV-negative people. Smear-negative TB occurs when TB-specific immune cells are unable to expel TB bacteria into the sputum; as a result, the smear microscopy test does not detect TB in the sputum sample. Extrapulmonary may occur when the immune system is unable to contain TB and the bacteria are able to spread to other parts of the body and infect organs. The WHO’s guidelines on improving diagnosis of smear-negative and extrapulmonary TB can be found at http://www.who.int/hiv/pub/tb/ pulmonary/en/index.html

!"46789:;'796<='AR' Bacille Calmette-GuÊrin (BCG) is the only approved TB vaccine, and saves the lives of an estimated 40,000 children each year. BCG is the most widely administered vaccine in the world but provides only limited and variable protection against two forms of extrapulmonary TB. It has been known to cause a potentially fatal immune inflammatory reaction in HIV-positive infants, "#'ITIS OR "#'OSIS WHICH IS NOT WELL UNDERSTOOD "UT IN BASED ON compelling evidence, the WHO recommended that BCG was not to be used in newborns with a confirmed HIV diagnosis. TB control programs focus on diagnosing and treating smear-positive pulmonary TB. Because smear-negative TB and EPTB are less infectious and less likely to cause symptoms, TB programs often prioritize their limited resources toward finding and treating the more infectious smearpositive pulmonary TB. And because smear-negative TB and EPTB are more associated with HIV infection, HIV-positive TB patients risk getting misdiagnosed or missed completely by TB control programs. Little data exists to guide how best to treat a person coinfected with TB and HIV with anti-TB medications and ARVs at the same time. There are a number of drug-to-drug interactions between anti-TB medications and ARVs that complicate optimal dosing and when to start HIV treatment. The current recommendation is to treat and cure the TB disease first, if possible, and then to initiate HIV treatment. If this is not an option because the patient’s HIV disease is advanced, it is recommended that HIV treatment be delayed for as long as possible until anti-TB treatment is tolerated and patient’s prognosis is improving. *For more information go to the TB Treatment module (expected February 2010), see the TB Diagnostics module (expected April 2010), the TB Vaccine module (expected June 2010), and TAG’s Pipeline Report, which can be found at http://www.treatmentactiongroup.org/publication.aspx?id=3212. RE Q. A.

VIEW Name one way that TB and HIV impact one another. A person who is TB/HIV coinfected is more likely to s PROGRESS FROM LATENT 4" INFECTION TO 4" DISEASE s HAVE PROGRESSIVE PRIMARY DISEASE

1010

s HAVE RECURRENCE OF 4" s HAVE SMEAR NEGATIVE 4" s HAVE EXTRAPULMONARY 4" Q. What is recurrent TB? A. Recurrent TB is a second episode of TB after a first episode was apparently cured. A recurrence of TB may be the result of relapse or reinfection. Q. Why is an HIV-positive person at greater risk for smear-negative TB? A. Because of impaired immune function, TB-specific immune cells may lose their ability to expel TB bacteria into the sputum; as a result, the smear microscopy test does not detect TB in the sputum sample. Note to facilitator : If par ticipants have difficulty with these questions, return to the slide to reinforce points they have not identified.

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S E C T I O N 3 TB/HIV COLLABORATIVE ACTIVITIES (slides 21–25; 20 minutes)

!"46789:;'796<='A> %T='"FD=C6E')H96G;'UHC +H99:\HC:D6]='*GD6]6D6=7 %T='H]=C:99'^H:9'67'DH ' <=GC=:7='DT='\IC<=F ' HU'%&':F<'!"#'6F ' <I:99;':UU=GD=<'8H8I9:D6HF X

0\_=GD6]=7, >X'@7D:\967T'DT='E=GT:F67E7' '''''UHC'GH99:\HC:D6HF'\=DS==F'%&' ''''':F<'!"#$*"4/'8CH^C:EE=7X' AX'4=GC=:7='DT='\IC<=F'HU'%&'6F')?-!*X'' KX'4=GC=:7='DT='\IC<=F'HU'!"#' '''''6F'%&'8:D6=FD7X

NICE TO KNOW The Stop TB Partnership was established in 1998; its aim is to realize the goal of eliminating TB as a public health problem and, ultimately, to obtain a world free of TB. It comprises a network of international organizations, countries, donors from the public and private sectors, governmental and nongovernmental organizations, and individuals that have expressed an interest in working together to achieve this goal. For more information go to http://www.stoptb.org/.

EXERCISE: ASK PARTICIPANTS IF THEY HAVE HEARD OF THE TB/HIV COLLABORATIVE POLICY. IF SO, CAN THEY NAME ANY OF THE RECOMMENDED ACTIVITIES?

!"46789:;'796<='AA In 2004, the Stop TB Partnership and the WHO, in conjunction with various TB and HIV stakeholders, developed the Interim Policy on Collaborative TB/HIV Activities. The policy was developed to assist policy makers in determining what should be done to decrease TB and HIV by promoting enhanced collaboration between TB and HIV/AIDS programs in providing care and service delivery to people with HIV and those with or at risk for TB.

!"46789:;'796<='AK The Interim Policy focuses on 12 key collaborative activities to be carried out by various stakeholders in order to achieve the three objectives: Establish the mechanism for collaboration A.1. TB/HIV coordinating bodies A.2. HIV surveillance among TB patient A.3. TB/HIV planning A.4. TB/HIV monitoring and evaluation To decrease the burden of TB in the person living with HIV/AIDS B.1. Intensified TB case finding B.2. Isoniazid preventive therapy

!"#$"%&'$()*+%$)'"(&",)-!./0 refers to actively trying to identify TB signs and symptoms in HIV-positive people—particularly those in high-TBprevalent settings. +6',#1F#$7"/%0%,4#0%74G%/1"*7:+.8= refers to provision of the anti-TB medication isoniazid to HIVpositive persons who are latently infected with TB in order to reduce the risk of progressing to active TB disease. !"1$*#&2")*2"#324)-!.0 comprises different strategies used to reduce TB transmission in high-TB-prevalent settings (e.g., hospitals and prisons). Infection control includes administrative measures (e.g., separating infectious TB patients), environmental measures (e.g., increasing air ventilation) and individual measures (e.g., having health care workers wear protective masks). 8G%74G/%%7+H6 refer to ICF, IPT, and IC—key activities in reducing the burden of TB among people with HIV.

*For more information on IPT and IPT, see the TB Treatment module; for more on the three I’s, see the Three I’s module.

B.3. TB infection control in health care and congregate settings C. To decrease the burden of HIV in TB patients C.1. HIV testing and counseling C.2. HIV preventive methods C.3. Cotrimoxazole preventive therapy C.4. HIV/AIDS care and support C.5. Antiretroviral therapy to TB patients *The Interim Policy for Collaborative Activities can be found at http://www.who.int/hiv/pub/tb/tbhiv/en/.

The three objectives focus on joint TB/HIV collaboration, decreasing the burden of TB among people with HIV, and decreasing the burden of HIV in TB patients. The first objective describes four activities that can be undertaken to strengthen coordination between TB and HIV programs. The second objective focuses on TB prevention, screening, and treatment activities that HIV programs should be implementing to reduce the risk of TB infection and disease progression among people with HIV. These activities, intensified case finding (ICF), isoniazid preventive therapy (IPT), and infection control (IC), are often referred to as the three I’s. It is important to note that these activities

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are not just the responsibilities of HIV clinicians and can be implemented and/or supported by communities. The third objective discusses HIV prevention, testing, and treatment activities that should be integrated into TB services.

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This chart shows the progress made around the world in implementing some of the collaborative activities recommended by the policy to reduce the burden of HIV among TB patients (HIV testing and counseling) and to reduce the burden of TB among people with HIV (intensified case finding and IPT to people with HIV). The data indicate that the TB programs have been more successful at implementing HIV services than the HIV programs have been in integrating TB diagnosis and treatment into their services. From 2003 to 2008, the percentage of TB patients being tested for HIV has increased fivefold, from 4 percent to 22 percent. While this is improvement, still less than half of all TB patients were tested for HIV. TB programs may be an important entry into HIV care and treatment for many people, particularly given that 25 percent of all TB/HIV coinfected cases were identified through HIV testing done at TB centers in 2008. On the other hand, no countries reported screening any people with HIV for TB in 2003, and by 2008, only 4 percent of people with HIV were screened FOR 4" #ONSIDERING THAT IN SOME HIGH 4" BURDEN COUNTRIES SUCH AS :IMBABWE AND 3OUTH !FRICA MORE THAN HALF OF ALL NEW 4" CASES WERE ()6 positive, TB screening should be a priority for HIV programs. As has been previously discussed, HIV-positive TB patients are far more likely to have smear-negative TB and EPTB, which is more difficult to diagnose and has fewer symptoms; therefore it is possible that there are many HIV-positive people who unknowingly have TB disease. Even when there is screening taking place and patients are identified as being latently infected with TB, fewer than 1 percent are offered IPT. In 2008, approximately 9.4 million of the 2 billion people who are latently infected with TB developed active disease, with most cases occurring in SUB 3AHARAN !FRICA %ASTERN %UROPE !SIA AND ,ATIN !MERICAˆREGIONS WHERE most countries do not offer preventive therapy. The refusal to provide this

1313

potentially lifesaving treatment occurs despite the mountain of evidence showing that 6 to 12 months of daily IPT is highly effective in decreasing the risk for developing TB disease among those with LTBI, particularly among people with HIV. Given the impact that TB and HIV have on one another, it is important for both TB and HIV programs to actively try to identify and appropriately treat persons who are TB/HIV coinfected.

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HIV Testing for TB patients is a critical entry point for interventions for both treatment and prevention. The progress in the number of TB patients being tested for HIV is encouraging. However, there is room for improvement, as illustrated by the high variability in current testing rates among regions. As has been previously mentioned, TB services can play a vital role in expanding access to HIV testing, care, and treatment. Almost half of all TB patients who were tested for HIV in sub-Saharan Africa were found to be HIV-positive. Likewise, in South-East Asia, where many countries are considered to have low HIV prevalent rates (less than 1 percent of the general population), 18 percent of TB patients tested were HIV positive, indicating that HIV infection rates are likely higher among TB patients than the general population.

.2#3&526+724$ is a broad-based antibiotic that is used to prevent several respiratory and parasitic infections in HIV-positive persons, and is recommended by the WHO and UNAIDS for all HIVpositive persons with active TB regardless of CD4 T-cell count.

*For more information on CPT, see the TB Treatment module.

Both the WHO and UNAIDS recommend cotrimoxazole preventive therapy (CPT) for all HIV-positive persons with active TB disease because it has been shown to reduce morbidity and mortality in HIV-positive persons regardless of TB status. CPT is a broad-based antibiotic that is used to treat several respiratory and parasitic infections. The chart shows us VARIABLE IMPLEMENTATION OF THIS STRATEGY WITH PERCENT COMPLIANCE OF the recommendation in the Africa region and just over one-third of national programs in the Americas region providing CPT. Highly active antiretroviral therapy (HAART) has been shown to have a significant impact on the incidence of tuberculosis among people with HIV. A study from South Africa showed that since the initiation of HAART, TB incidence among people on HAART decreased significantly while TB incidence remained stable among HIV-negative and HIV-positive individuals not on

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HAART. Likewise, TB mortality rates among HIV-positive people were brought down to levels comparable to that of HIV-negative individuals. However, the percentage of HIV-positive TB patients being put on HIV treatment is variable; REGIONS WITH THE HIGHEST 4" ()6 COINFECTION RATEˆTHE 7ESTERN 0ACIlC !FRICA AND 3OUTHEAST !SIAˆPROVIDED ()6 TREATMENT TO BETWEEN JUST AND percent of HIV-positive TB patients. REVIEW: Q. Name the three objectives of the Interim Policy on TB/HIV Collaborative Activities. A. 1. To establish the mechanisms for collaborations between TB and HIV/ AIDS programs. 2. To decrease the burden of TB in people living with HIV. 3. To decrease the burden of HIV in TB patients . Q. What are the three I’s? A. The three I’s are key activities in reducing the burden of TB among people with HIV. 1. Intensified case finding (ICF) refers to actively trying to identify TB signs and symptoms in HIV-positive people, particularly those in highTB-prevalent settings. 2. Isoniazid preventive therapy (IPT) refers to provision of the anti-TB medication isoniazid to HIV-positive persons who are latently infected with TB in order to reduce the risk of progressing to active TB disease. 3. Infection control (IC) is a series of different strategies used to reduce TB transmission in high TB-prevalent settings (e.g., hospitals and prisons). Infection control includes administrative measures (e.g., separating infectious TB patients), environmental measures (e.g., increasing air ventilation) and individual measures (e.g., having health care workers wear protective masks). Q. Name one activity that can reduce the burden of HIV among TB patients. A. HIV testing and counseling; HIV preventive methods; cotrimoxazole preventive therapy; HIV/AIDS care and support; antiretroviral therapy to TB patients. Note to facilitator : If par ticipants have difficulty with these questions, retrun to the slide to reinforce points they have not identified.

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S E C T I O N 4 Advocacy Priorities (slides 26–27; 5 minutes)

!"46789:;'796<='AN EXERCISE: ASK THE GROUP MEMBRS WHAT THEY WOULD CONSIDER TO BE TWO OF THE MOST PRESSING ISSUES AROUND TB/HIV COLLABORATION WHERE THEY WORK. USE THIS TO START A LIST OF ADVOCACY PRIORITIES.

!"46789:;'796<='AO HIV activists have an important role to play in ensuring the implementation of TB/HIV collaborative activities. By becoming science-based activists for better TB research, services, and policies we can contribute to increased resources and political support for TB diagnosis and treatment. Twenty-three years after the first reports of HIV-associated TB, neither TB- nor HIV-control programs have adequately addressed TB/HIV issues. HIV activism has shown that a science-based approach to health care advocacy can be effective and powerful. In the United States, the beginning of the AIDS epidemic was characterized by inaction and indifference on the part of the government, the pharmaceutical industry, and, to an extent, academia. In a short period of time the AIDS activist movement made inroads in all AREAS LEADING TO CHANGES IN THE WAY DRUGS WERE STUDIED AND APPROVED AND massive increases in funding for research. As a result, today we have a rapid, highly sensitive, and easy-to-use diagnostics test for HIV, six different classes of anti-HIV drugs, and over four million people on HIV treatment. TB has suffered from neglect for too long. No new drugs have been developed to treat TB in over 40 years. Too few advances in the diagnosis, treatment, and prevention of TB have occurred during this time. Funding for research and programming is woefully insufficient compared to the global burden of disease. WHO expects that funding for TB control will reach US$4.1 billion in 2010, but this still represents a funding gap of US$ 2.1 billion. Despite the existence of the Interim Policy on Collaborative TB/HIV Activities, the public sector, civil society, and the medical community have failed to adequately implement the activities that address reducing the burden of TB and HIV in populations affected by both diseases. In many countries national TB programs and national AIDS control programs run as parallel systems without a mechanism to link to one another. The overlap between the AIDS and TB pandemics as well as the HIV activism model provides an opportunity to make real headway in the fight against TB. The TB and HIV pandemics fuel each other, so the most effective strategies for addressing them must take this in to account. Therefore HIV activists must integrate TB into their advocacy priorities. RESOURCES 1. The AIDS Epidemic Update 2009 can be found at: http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/ EpiUpdArchive/2009/default.asp. 2. The Global Plan to Stop TB 2006–2015 can be found at: http://www.stoptb.org/globalplan/ 3. Global Tuberculosis Control 2009: Epidemiology, Strategy, Financing can be found at: http://www.who.int/tb/publications/global_report/2009/en/index.html. 4. Global Tuberculosis Control: A Short Update to the 2009 Report can be found at http://www.who.int/tb/publications/global_report/en/.

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5. Improving the Diagnosis and Treatment of Smear-negative Pulmonary and Extra-pulmonary Tuberculosis among Adults and Adolescents: Recommendations for HIV-prevalent and Resource-constrained settings can be found at: http://www.who.int/hiv/pub/tb/pulmonary/en/index.html. 6. The Interim Policy on Collaborative TB/HIV Activities can be found at http://whqlibdoc.who.int/hq/2004/who_htm_tb_2004.330.pdf. ,AWN 3 ET AL h#HANGING MORTALITY RISK ASSOCIATED WITH #$ CELL response to antiretroviral therapy in South Africa.� 2009. AIDS 23:335– 342 can be found at: http://journals.lww.com/aidsonline/Abstract/2009/01280/Changing_ MORTALITY?RISK?ASSOCIATED?WITH?#$ ?CELL ASPX 8. The TAG Pipeline Report can be found at: http://www.treatmentactiongroup.org/publication.aspx?id=3212. 9. TAG’s 2009 Report on Tuberculosis Research Funding Trends, 2005–2008 can be found at: http://www.treatmentactiongroup.org/ publication.aspx?id=3404

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