Integrating TB into the HIV Response TB/HIV Shadow Reports to Review UNGASS Progress for 2009 in Kenya, Uganda, and Zambia
Why Is It Necessary to Monitor TB/HIV Indicators for UNGASS? Despite being curable, Tuberculosis (TB) continues to be the leading cause of death among people with HIV in 2008, accounting for 25% of all HIV-related deaths.1 The World Health Organization (WHO) has developed a 12-point policy package and recommended collaborative activities to address the TB/HIV coepidemic. The WHO recommended activities to address TB/HIV coinfection include establishing mechanisms of collaboration between TB and AIDS programs, activities to reduce the burden of HIV in TB patients, and a set of activities that are to be led by national AIDS programs (NAPs) to reduce the burden of TB among people with HIV. The WHO recommended activities that should be implemented by AIDS programs are comprised of three interventions jointly known as the “Three I’s”: intensified TB case finding (ICF) among people with HIV, TB infection control (IC), and isoniazid preventive therapy (IPT). Despite the strides in the scale-up of antiretroviral therapy (ART) to reach more than four million people at the end of 2008, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that only 42% of people in need are getting access to HIV treatment.2 As the WHO guidelines for ART eligibility were revised upward in 2009 from a CD4 cell count of 200 to 350, the number of people who are eligible for ART but are unable to access it has increased. In light of this fact, there is urgent need to scale up all programs that can keep people with HIV healthy, even as we advocate for the expedited rollout of ART to achieve universal access. Implementing all of the WHO’s recommended TB/HIV collaborative policies can significantly contribute to reducing disease and death among people with HIV. Despite this, the NAPs have not demonstrated leadership in integrating the Three I’s into services that are offered to people with HIV. The 2009 WHO report shows that of all of the recommended TB/HIV collaborative activities, the Three I’s were the least implemented. In 2008 only 1.6 million of the estimated 33 million people with HIV were screened for TB, and less than 1% of the estimated number of people coinfected with TB/HIV were given access to IPT; data on IC was not reported.3 1 2 3 4
In order to assist in advocacy toward the uptake of the Three I’s and to streamline the monitoring of TB/HIV collaborative services, the TB and HIV departments of the WHO, along with UNAIDS; the Global Fund for AIDS, TB, and Malaria (GFATM); and the U.S. President’s Plan for AIDS Relief (PEPFAR) have come together to agree upon 13 monitoring indicators that all of them use to track the Three I’s. As part of this strategy, the UNAIDS United Nations General Assembly Special Session on HIV/AIDS (UNGASS) country reports that track compliance with the Declaration of Commitment to universal access to HIV are also required to report on the 13 TB/HIV indicators.4
Activist TB/HIV Monitoring Efforts Treatment Action Group (TAG) and the International Community of Women Living with HIV–Eastern Africa (ICW) have been encouraging Africa-based HIV activists to become involved in TB/HIV advocacy. As part of this effort, TAG and the ICW have partnered to conduct TB/HIV treatment, science, research, and policy literacy workshops. To support activist-led UNGASS TB/HIV shadow reports, the ICW developed a survey to measure the 13 TB/HIV indicators and trained a core of activists in Kenya, Uganda, and Zambia to implement the survey. The activists chose districts of these countries that have high TB/HIV burdens and collected data through one-on-one interviews with program implementers such as AIDS and TB clinic heads, policy makers such as national TB program staff, and people who were living with TB and HIV and accessing the TB/HIV collaborative services. These report cards are a product of this activist-led TB/HIV monitoring exercise to ensure greater inclusion of TB/HIV indicators in the UNGASS country reports to UNAIDS and to track how well country TB and HIV programs are collaborating to reduce the burden of TB/HIV. The activists conducted their monitoring in September–November 2009. The report card was based on the data gathered for specific indicators pertaining to each of the 12 points of the WHO’s recommended collaborative TB/HIV activities. The full country reports that covers each of the TB/HIV indicators can be downloaded from http://treatmentactiongroup.org/ungassreports.aspx
World Health Organization. Global Tuberculosis Control: A Short Update to the 2009 Report. Geneva, Switzerland: World Health Organization, 2009. UNAIDS. AIDS Epidemic Update .Geneva, Switzerland: UNAIDS, 2009. World Health Organization. Rapid Advice: Antiretroviral Therapy for HIV Infection in Adults and Adolescents. Geneva, Switzerland: World Health Organization, 2009. Stop TB Partnership. Monitoring and Evaluation: Harmonization, 2009. Retrieved 28 July 2009 from http://www.stoptb.org/wg/tb_hiv/issues_monitor.asp