MODULE TWO TB/HIV Epidemiology & Impact Treatment Action Group TB/HIV Advocacy Toolkit 1
Topics to be covered Global and regional estimates of TB, HIV and TB/HIV coinfection How do TB and HIV impact one another? What are the recommended TB/HIV collaborative activities? Advocacy priorities
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Section 1: Global & regional statistics
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Global estimates of TB It is estimated that one-third of the world is infected with TB There were an estimated 9.4 million new cases of TB in 2008 – An estimated 1.4 million (16%) were HIV positive – 3.6 million were among women
There were an estimated 1.8 million deaths - equal to 4,500 deaths per day – 500,000 of which occurred among people with HIV - TB accounted for nearly 25% of all HIV deaths
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Global TB estimates 2007-08 All forms of TB Greatest number of cases in Asia; greatest rates per capita in Africa Multidrug-resistant TB (MDR-TB) Extensively drugresistant TB (XDR-TB) HIV-associated TB
Estimate Estimate d number d number of new of cases deaths 9.4 million 1.8 million 500,000 ~
50,000
1.4 million (16%)
150,000
~
30,000
~
500,000
Based on data from WHO Stop TB Department
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Regional TB incidence 2007
Estimated new TB cases (all forms) per 100 000 population No estimate 0-24 25-49 50-99 100-299 >= 300
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
Based on data from WHO Stop TB Department
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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
22 High TB-burden countries
Afghanistan Bangladesh Brazil Cambodia China Democratic Republic of Congo Ethiopia India Indonesia Kenya Mozambique Myanmar Nigeria Pakistan Philippines Russian Federation South Africa United Republic of Tanzania Thailand Uganda Viet Nam Zimbabwe
Based on data from WHO Stop TB Department
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What is MDR-TB? And XDRTB?
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MDR/XDR TB  Multi-drug resistant TB (MDR-TB) is a form of TB that is resistant to isoniazid and rifampicin, two of the most powerful first-line drugs.  Extensively drug resistant TB (XDR-TB) 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). 9
MDR-TB among new cases 1994-2007 Global estimate: about 500,000 new MDR-TB cases a year
0.00 - 0.99 1.00 - 2.99 3.00 - 5.99 6.00 – 10.00 >10.00 No data * Sub-national coverage in India, China, Russia, Indonesia.
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 2006. All rights reserved
Based on data from WHO Stop TB Department
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Countries with confirmed XDR-TB - 2007 Italy
Armenia
Japan
Azerbaijan
Latvia
Australia
Lesotho
Bangladesh
Lithuania
Botswana
Mexico
Brazil
Moldova
Canada Chile
Mozambique Namibia
China, Hong Kong SAR Czech Rep.
Nepal
Estonia
Norway
France
Peru
Georgia
Philippines
Germany
Poland
India
Portugal Rep of Korea
Islamic Rep. of Iran Israel
Russian Fed.
Netherlands
Ecuador
Ireland
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 WHO 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 2005. All rights reserved
Argentina
Romania
Slovenia South Africa Spain Swaziland Sweden Thailand UK USA
Ukraine
Vietnam
Based on information from WHO Stop TB Department
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Global HIV/AIDS estimates 2008 Number of people with HIV: 33.4 million (31.1 - 35.8 M)
New HIV Infections: 2.7 million (2.4 - 3.0 M)
Deaths due to HIV : 2.0 million (1.7 - 2.4 M) Based on data from WHO/UNAIDS
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Adults and children estimated to be living with HIV - 2008
1.4 million
Caribbean
Eastern Europe & Central Asia
[710 000 – 970 000]
[1.4 – 1.7 million]
850 000
North America [1.2 – 1.6 million]
Western & Central Europe
1.5 million
Middle East & North Africa
240 000
[220 000 – 260 000]
Latin America
2.0 million
[1.8 – 2.2 million]
310 000
[250 000 – 380 000]
Sub-Saharan Africa
22.4 million
[20.8 – 24.1 million]
East Asia
850 000
[700 000 – 1.0 million]
South & South-East Asia
3.8 million
[3.4 – 4.3 million]
Oceania
59 000
[51 000 – 68 000]
Total: 33.4 million (31.1 – 35.8 million) Based on data from WHO/UNAIDS
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The Overlap between TB and HIV 11 million (TB and HIV co-infected)
TB infection 2 billion
HIV infection 33 million
Based on data from WHO Stop TB Department
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Estimated HIV prevalence in new TB cases, 2008
Based on data from WHO Stop TB Department
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63 High TB/HIV-burden countries
Africa Region: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Cote d'Ivoire, Congo, DR Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Mali, ,Malawi, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sierra Leone, South Africa, Somalia, Swaziland, Togo, UR Tanzania, Uganda, Zambia and Zimbabwe. (38 countries) East Mediterranean region: Djibouti and Sudan. (2 countries) American region: Bahamas, Barbados, Belize, Brazil, Dominican Republic, Guatemala, Guyana, Haiti, Honduras, Jamaica, Suriname, Panama and Trinidad & Tobago. (13 countries) South East Asia Region: India, Indonesia, Myanmar and Thailand. (4 countries) Western Pacific region: Cambodia, China and Viet Nam. (3 countries) European region: Ukraine, Russian Federation and
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Section 2: TB/HIV impact
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How do TB and HIV impact one another? People who are coinfected with TB and HIV are at increased risk for: – Progressing from latent TB infection to active TB disease – Progressive primary TB disease (skipping over latent TB infection) – TB recurrence (a second episode of TB) – Smear-negative TB (low baciliary load)
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How do TB and HIV impact one another? Vaccines
BCG is not recommended for HIVpositive children
Diagnostics The most commonly used TB diagnostic tools lack the sensitivity to detect smear-negative and extrapulomary TB
Treatment
Difficult to dose anti-TB treatment
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Section 3: TB/HIV Collaborative activities
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The Interim Policy for Collaborative Activities The overall goal is to decrease the burden of TB and HIV in dually affected population.
Objectives: 1. Establish the mechanisms for collaboration between TB
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Collaborative TB/HIV activities A.
B.
C.
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 Is) – – – To – – – – –
decrease the burden of TB in PLHIV (Three B.1. Intensified TB case finding (ICF) B.2. Isoniazid preventive therapy (IPT) B.3. TB infection control (IC) decrease the burden of HIV in TB patients C.1. HIV testing and counselling C.2. HIV preventive methods C.3. Cotrimoxazole preventive therapy (CPT) C.4. HIV/AIDS care and support C.5. Antiretroviral therapy to TB patients. 23
Trends in TB/HIV collaborative services from 2003-2008 % of TB tested for HIV
% of estimated TB/HIV detected
% of PLHIV screened for TB
% of PLHIV placed on IPT
2003
4%
2%
0.0%
0.026%
2004
3%
3%
0.3%
0.038%
2005
8%
7%
0.6%
0.081%
2006
12%
14%
1.0%
0.084%
2007
20%
23%
1.9%
0.089%
2008
22%
25%
4.1%
0.145%
Based on data from WHO Stop TB Department
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HIV testing and treatment2008 Regio n
% of TB patients tested for HIV
% of tested TB patients HIV positive
% of identified TB patients on CPT
% of identified TB patients on ART
AFR
45
46
73
30
AMR
49
15
36
67
EMR
5.4
4.1
39
55
EUR
79
3.3
61
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SEAR
4.1
18
54
35
WPR
11
7
55
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Globa l
22
26
71
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Based on data from WHO Stop TB Department
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Section 4: Advocacy Priorities
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Advocacy priorities At the national and global levels, AIDS control and TB control programs both programs need to address TB/HIV coinfection – People with HIV need to be routinely screened for TB and given appropriate treatment – People with TB or at risk for TB should be counseled and tested for HIV, and be offered appropriate treatment
HIV activists need to become science-based activists for TB research, treatment, and policy so that we can contribute to increased resources and political support for TB and TB/HIV. – It is expected that there will be a funding shortfall for TB of US$2.1 billion in 2010 – Current tools to prevent, diagnose and treat TB are not sufficient • BCG vaccine is not recommended for use in HIV-positive children; • The most commonly used diagnostic tool (smear
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