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Treatment Action GroupTB/HIV Advocacy Toolkit

MODULE TWO TB/HIV Epidemiology & Impact

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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

Estimated number of new cases

Estimated number

of deaths

1.8 million1.8 million9.4 million9.4 million

~150,000 500,000

All forms of TB Greatest number of cases in Asia; greatest rates per capita in AfricaMultidrug-resistant TB (MDR-TB)

Extensively drug-resistant TB (XDR-TB) ~50,000 ~30,000

HIV-associated TB 1.4 million (16%)

500,000Based on data from WHO Stop TB Department

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Estimated new TB cases (all forms) per 100 000 population

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

No estimate

0-24

50-99

>= 300

25-49

100-299

Regional TB incidence - 2007

Based on data from WHO Stop TB Department

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22 High TB-burden countries

1. Afghanistan 2. Bangladesh 3. Brazil 4. Cambodia 5. China 6. Democratic

Republic of Congo

7. Ethiopia 8. India 9. Indonesia 10. Kenya 11. Mozambique 12. Myanmar 13. Nigeria 14. Pakistan 15. Philippines 16. Russian

Federation 17. South Africa 18. United Republic

of Tanzania 19. Thailand 20. Uganda 21. Viet Nam 22. Zimbabwe

Based on data from WHO Stop TB Department

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What is MDR-TB? And XDR-TB?

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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).

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0.00 - 0.991.00 - 2.993.00 - 5.996.00 – 10.00>10.00No data

* Sub-national coverage in India, China, Russia, Indonesia.

MDR-TB among new cases 1994-2007

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

Global estimate: about 500,000 new MDR-TB cases a year

Based on data from WHO Stop TB Department

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Czech Rep.

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

Ecuador

Georgia

Argentina

Bangladesh

Germany

Rep of Korea

Armenia

Russian Fed.

South Africa

Portugal

Latvia

Mexico

Peru

USA

Brazil

UK

Sweden

Thailand

Chile

Spain

China, Hong Kong SAR

France

Japan

Norway

Canada

Italy

Netherlands

Estonia

Lithuania

Ireland

RomaniaIsrael

Azerbaijan

Poland

Slovenia

India

Australia

Mozambique

Vietnam

Ukraine

Moldova

Philippines

Botswana

Nepal

Islamic Rep. of Iran

Lesotho

Swaziland

Namibia

Countries with confirmed XDR-TB - 2007

Based on information from WHO Stop TB Department

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Global HIV/AIDS estimates 2008

Based on data from WHO/UNAIDS

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)

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Total: 33.4 million (31.1 – 35.8 million)

Western & Central Europe

850 000850 000[710 000 – 970 000][710 000 – 970 000]

Middle East & North Africa310 000310 000

[250 000 – 380 000][250 000 – 380 000]

Sub-Saharan Africa22.4 million22.4 million

[20.8 – 24.1 million][20.8 – 24.1 million]

Eastern Europe & Central Asia

1.5 million 1.5 million [1.4 – 1.7 million][1.4 – 1.7 million]

South & South-East Asia3.8 million3.8 million

[3.4 – 4.3 million][3.4 – 4.3 million]

Oceania59 00059 000

[51 000 – 68 000][51 000 – 68 000]

North America1.4 million

[1.2 – 1.6 million]

Latin America2.0 million2.0 million

[1.8 – 2.2 million][1.8 – 2.2 million]

East Asia850 000850 000

[700 000 – 1.0 million][700 000 – 1.0 million]Caribbean240 000

[220 000 – 260 000]

Adults and children estimated to be living with HIV - 2008

Based on data from WHO/UNAIDS

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The Overlap between TB and HIV

TB infection HIV infection

11 million (TB and HIV co-infected)

2 billion

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 Estonia. (3 countries)

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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)– Extrapulmonary TB (TB outside of lungs)

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How do TB and HIV impact one another?

VaccinesBCG is not recommended for HIV-positive children

DiagnosticsThe most commonly used TB diagnostic tools lack the sensitivity to detect smear-negative and extrapulomary TB

TreatmentDifficult to dose anti-TB treatment and ARVs at the same time

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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 and HIV/AIDS programmes. 2. Decrease the burden of TB in PLWHA. 3. Decrease the burden of HIV in TB patients.

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Collaborative TB/HIV activities

A. 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

B. To decrease the burden of TB in PLHIV (Three Is)– B.1. Intensified TB case finding (ICF)– B.2. Isoniazid preventive therapy (IPT)– B.3. TB infection control (IC)

C. To 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.

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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 treatment- 2008

Region

% 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 30AMR 49 15 36 67EMR 5.4 4.1 39 55EUR 79 3.3 61 29SEAR 4.1 18 54 35WPR 11 7 55 28Global

22 26 71 32

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 microscopy) misses up to 50% of cases in people with HIV; and

• Some of the most powerful anti-TB medications cannot be used in conjunction with ARVs.