Scaling up HIV/TB collaborative activities in the Western Pacific

World Health Organization

Western Pacific Region

Scaling up HIV/TB Scaling up HIV/TB collaborative activitiescollaborative activitiesin the Western Pacificin the Western Pacific

Massimo N GhidinelliMassimo N Ghidinelli

HSI WPROHSI WPRO

From Mekong to Bali HIV/TB ConferenceFrom Mekong to Bali HIV/TB Conference

8-9 August 2009 8-9 August 2009 Bali, IndonesiaBali, Indonesia



Outline• Context: HIV TB epidemics and

responses in WPR

• Mekong Conference 2004: objectives and output

• Progress in implementing collaborative activities

• Challenges and ways forward



World Health Organization Western Pacific Region



Surveillance of HIV-STI, WPR countries, Surveillance of HIV-STI, WPR countries, as of June 09as of June 09

Country

BSS HSS SSS Studies/STI &

behaviour

DHS with HIV

TB ptsincluded in HSS

(in rounds)

Cambodia 7 8 3 √ 2 √

China >10 >10 >10 √

Malaysia 1 5 √ √ (screenin

g)

Mongolia 5 5 5 √

Laos 3 3 3 √

Papua New Guinea 2 7 1 √ 1 √

Philippines >10 >10 >10 √ 1

Viet Nam 2 >10 2 √ 1 √

PICs (Fiji, Kiribati, Samoa, Sol Is,

Tonga, Vanuatu)**

2 2 2 √



Estimates 2001 2007Total living with HIVTotal living with HIV

• ChildrenChildren0.750 M0.750 M

5,2005,2001.3 M1.3 M

21,00021,000

Adults living with HIVAdults living with HIV• Prevalence ratePrevalence rate• FemaleFemale

0.745 M 0.745 M

0.1%0.1%

180,000180,000

1.28 M 1.28 M

0.1%0.1%

340,000340,000

New HIV infectionsNew HIV infections • Adult Adult • ChildrenChildren

130,000 130,000

3,000 3,000 145,500145,500

4,5004,500

AIDS death AIDS death • Adult Adult • ChildrenChildren

28,00028,000

1,9001,90060,000 60,000

3,000 3,000 Source: adapted from UNAIDS-WHO, 2001-2007

Regional HIV estimates, Regional HIV estimates, WPR 2001 - 2007WPR 2001 - 2007



ART in Western Pacific RegionART in Western Pacific Region

Sources: Towards UA: Scaling up priority intervention in the health sector, Progress Report 2007-2009, WHO/UNAIDS/UNICEF

CountryCountry

Patients on ART Patients on ART 2004 2004

Patients on Patients on ART 2006ART 2006

Patients on Patients on ART 2007ART 2007

Tot on ART, Tot on ART, 2008 (Children)2008 (Children)

CambodiCambodiaa

45274527 20 13120 131 27 00027 000 31 999 (3 067)

ChinaChina 82198219 31 14031 140 35 00035 000 48 254 (1 120)

FijiFiji -- -------- <100<100 39

LaosLaos 104104 479479 700700 1 009 (72)

MalaysiaMalaysia 27002700 -------- 68006800 8 197

MongoliaMongolia 22 <100<100 5

PNGPNG 60, <20060, <200 10981098 23002300 5 195 (275)

PhilippinPhilippineses

71, <20071, <200 170170 <500<500 532

Viet NamViet Nam 300, <500300, <500 83108310 17 00017 000 27 059 (1 462)

WPRWPR 16 17016 170 61 13061 130 89 00089 000 122,289(5 996)



TB burden - notification rates (all TB) TB burden - notification rates (all TB) in Western Pacific (2007)in Western Pacific (2007)

Source: TB Control in WPR: 2009 Report



Incidence rates stable or falling Incidence rates stable or falling slowlyslowly

0

50

100

150

200

250

300

350

400

Ca

se

s p

er

10

0,0

00

p

op

ula

tio

n

Africa

South-East Asia

WORLD

Western Pacific

EasternMediterranean

Europe

Americas

Cases in millions

02468

10

1990

1994

1998

2002

2006

Source: Global TB Control 2008



HIV prevalence in new TB cases HIV prevalence in new TB cases (2007)(2007)

0

4

8

12

16

20

Mo

ng

oli

a

Ph

ilip

pin

es

Jap

an

Repu

bli

c o

f K

ore

a

New

Zeala

nd

Ch

ina

Fij

i

Au

stra

lia

Lao

Peo

ple

's D

em

ocra

tic

Repu

bli

c

Sin

gap

ore

Cam

bo

dia

Vie

t N

am

Mala

ysi

a

Pap

ua N

ew

Gu

inea

HIV

pre

vale

nce (

%)

HBC

Source: TB Control in the WPR 2009 Report



Estimated morbidity and mortality due Estimated morbidity and mortality due to TB/HIV co-infection in the Western to TB/HIV co-infection in the Western

PacificPacificEstimated TB/HIV burden in the Western Pacific

(selected countries)

51,483

24,705

12,052

5,560

4,433

2,930

874

295

14,503

6,774

3,101

1,843

1,296

1,049

271

99

0 10,000 20,000 30,000 40,000 50,000

WPR Total

China

Viet Nam

Cambodia

Malaysia

Papua New Guinea

Philippines

Lao PDR

Number

Number of TB/HIV deaths

Number of TB/HIV cases

Source: Global Tuberculosis Control 2009, WHO, Geneva



Mekong Meeting 2004Mekong Meeting 2004RationalRational

• HIV fuels TB epidemic & threatens TB control

• Limited data on HIV/TB co-infection and low awareness

• Lack of collaboration between NTP and NAP

• ART scale up (3by5) and role of NTP



HIV-positive TB cases identified HIV-positive TB cases identified through testing for HIV in 2005through testing for HIV in 2005

Towards UA. Scaling up priority HIV/AIDS interventions in the health sector. Progress Report, WHO, Geneva, April 2007



TB and HIV in HCM City

0

50

100

150

200

250

Ra

te p

er

10

0,0

00

0

2

4

6

8

10

Pe

rce

nta

ge

New SS+

All forms

TB fatality rate

TB/HIV

Source: Presented at Mekong Meeting, HCMC 2004



High Early Mortality Rate (in High Early Mortality Rate (in 2004)2004)

• Mortality rate during TB treatment between 20% - 50%– Multiple provinces, Thailand– Ho Chi Minh City, Viet Nam– Phnom Penh, Cambodia

• Most deaths occur within 2 months of TB diagnosis

• Most patients diagnosed with HIV at the same time as diagnosed with TB

Source: Presented at Mekong Meeting, HCMC 2004



Objectives of the Mekong MeetingObjectives of the Mekong Meeting

• Increase awareness and commitment• Share experiences on HIV/TB activities• Discuss WHO 2004 framework and

guidelines• Identify obstacles for collaboration• Discuss ART and the role of NTP and

NAP



Outcome of Mekong Outcome of Mekong ConferenceConference

• 127 participants from 11 countries, 5 day meeting

• Experiences, lessons learned shared: 6 focus countries + partner organizations

• WHO WPRO TB/HIV framework discussed

• Country action plans developed & presented (Cambodia, China, Laos, Myanmar, Thailand, Viet Nam) pilot phase



First First Regional Regional TB-HIV TB-HIV

FrameworFramework k

20042004



TB facilities HIV/AIDS facilities

TB suspect

TB screening

No TB HIV (+)

HIV suspect

HIV testing

Active TB HIV (-)

2004 Regional framework: 2004 Regional framework: Referral systemReferral system



Referral-based approach

• Uptake of testing inadequate– Diagnoses missed or delayed– Mortality rate high

• Infectious TB patients sent to sites with many people living with HIV

• Heterogeneity of HIV epidemics

• Limited collaboration HIV-TB Programmes



Slow implementation in WPR

2005 (%) 2006 (%)

% new TB tested for HIV 0.6 3.2

% CPT among HIV-TB 0.5 42

% ART among HIV-TB% TB Screened PLWHA

1.6

?

22

?



A revised A revised framework framework in 2008 to in 2008 to address address

TB-HIV co-TB-HIV co-infection infection

in the Western in the Western Pacific RegionPacific Region



Aims of revised Aims of revised frameworkframework

• Conduct TB/HIV surveillanceTB/HIV surveillance as appropriate to the epidemiologic context

• Diagnose HIV and TB as early as possible through early HIV testingHIV testing of TB patients and TB screeningTB screening of people living with HIV

• Ensure that people with both TB and HIV have early access to life-saving treatmenttreatment

• Improve infection controlinfection control at TB and HIV care facilities

• PreventPrevent new cases of HIV and TB



HIV testing facility: HIV+

TB facility - suspectsOn-site HIV testing & counselling offered

HIV care facilityPost-test counsellingCD4, ART, CPTRoutine TB screening & DxStart IPT if no TB

TB +, HIV +

TB +, HIV -TB –HIV +

TB facilityTB treatmentCPTART (special cases) Otherwise, refer to HIV tx facility

HIV care facility, TB+Post-test counsellingART/CPTTreat TB or refer for treatment

TB facilityTB treatmentPrevent HIV

Patient flow in revised framework



Policies and Services on TB/HIV in Policies and Services on TB/HIV in 20082008

Country Services available to screen TB for PLHA

INH prophylaxis for PLHA

IPT as part of HIV care

Infection control policy for TB in facilities

Brunei Darussalam no no no yes

Cambodia yes no no yes

China yes no yes

Fiji yes no no

Lao PDR yes no no yes

Malaysia yes no no yes

Mongolia yes no no yes

Papua New Guinea yes yes yes yes

Philippines yes no yes yes

Singapore yes

Viet Nam yes no no yes

Source: Country reports for Universal Access Progress Report 2007 and 2008. Data of 2008 are provisional.



HIV/TB collaborative activities 2007-2008 HIV/TB collaborative activities 2007-2008 in WPR countriesin WPR countries

CountryNo. (%) HIV+ incident TB cases that received treatment for TB

and HIV

No. (%) newly-enrolled in HIV care given isoniazid preventive

therapy (IPT)

No. (%) of those enrolled in HIV care who had TB status assessed and recorded during

their last visit

2007 2008 2007 2008 2007 2008

Cambodia NA NA NA NA NA (85.7 in 1 site)

China NA NA NA NA NA NA

Fiji 1 NA 0 2 (100) 9 11 (14)

Laos 453 293 NA NA 131 (71.6) NA

Malaysia 72 (33.5) 30 NA NA 2002 (89.3) 1958 (88.0)

Mongolia NA 0 0 0 (0) 4 (12.5) 10 (26.0)

Philippines 9 (49.3) 129 (46.0) NA NA NA NA

PNG 320 555 (8.0) 215 (29.8) 47 (2) 870 (38.7) 1487 (67.0)

Viet Nam NA NA NA NA NA NA

Source: Country reports for Universal Access Progress Report 2007 and 2008. Data of 2008 are provisional.



Reported TB/HIV data Reported TB/HIV data (2007)(2007)

Source: Global TB Control 2009, WHO Geneva

All notified

TB cases

# of TB cases tested

for HIV

Of which tested +ve

for HIV

Of HIV +ve, # of

cases on CPT

Of HIV +ve, # of

cases on ARV

China1,045,93

934,557 (3.3%)

1,187 (3.4%)

679 519

Vietnam 98,344 14,377 (15%) 627 (4.4%) NA NA

Cambodia 36,495 14,245 (39%)2,922 (21%)

1,101 610

Malaysia 16,918 10,082 (60%)1,629 (16%)

NA NA

Lao PDR 4,010 424 (11%) 155 (37%) 149 75



Steps for TB-HIV Scale-up

1. Revised framework drafted 2007-082. Draft discussed with TB and HIV

Programme Managers in Cambodia, February, 2008

3. Revised framework printed-out4. Advice/Recommendations by TAG5. Country-level framework developed6. Scale-up TB-HIV activities at

countries



• Enhance collaboration HIV-TB Programmes

• Monitoring and reporting of HIV/TB collaborative activities

• Extend HIV testing (rapid tests) to TB clinics

• Provision of CPT, IPT

Challenges in HIV/TBChallenges in HIV/TB



• Dr Pieter van Maaren, StopTB WPRO

• Dr Katsunori Osuka, StopTB WPRO

• Dr Nguyen Thuy, HSI WPRO

• Dr Yu Dongbao, HSI WPRO

AcknowledgmentsAcknowledgments

Scaling up HIV/TB collaborative activities in the Western Pacific

Documents

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