TB and HIV Management in High HIV Prevalence Settings: the Policy Perspective

Kevin M. De CockCenter for Global Health

Centers for Disease Control and Prevention

Integration Blues

Why integrate?• Improved health outcomes• Better service performance• Increased efficiency• Cost savings• Patient/client convenience

Potential adverse effects:• Erosion of technical quality• Loss of accountability• Lowering of morale• Nosocomial infection

Two, four, six, eight,Time to go and integrate….

Tom Lehrer

Policy, Regulations and Guidelines

• PolicyA course of action (or inaction) usually taken by authorities with regard to a particular set of issues

The “what” and “why”

• Regulations and GuidelinesTools to implement a particular policy choice

The “how”, “when” and “where”

Cases in millions

02468

10

19901994

19982002

2006

LargestImpact

SmallestImpact

Factors that affect health

ExamplesCondom use

Tuberculosis treatment

Male circumcision

Socioeconomic Factors

Changing the Contextto make individuals’ default decisions healthy

Long-lasting Protective Interventions

ClinicalInterventions

Counseling & Education

Poverty, education, housing, inequality

Functioning public health system, universal access

Policy and the Evidence Base

Evidence• Science should drive public

health policy• “Evidence-based” or

“evidence-informed”?• “Everyone is entitled to his

own opinion, but not to his own data”

Values • Human rights • Social justice • Dignity• Ethics and morals• Politics• “The duty to protect”

6 GH Friedland, MD

Which model of collaboration ?

TB HIV/AIDS

TB AIDS TB/AIDS

SeparateTB/ HIV patients referral

FullOne stop service for TB-HIV co-infected

TB AIDS

PartialSome mixing

7 GH Friedland, MD

Current and Optimal TB and HIV Program Paradigms

Current TB and HIV Programs Paradigm

Optimal TB and HIV Programs Paradigm

National TB Program

HIV Services

VCTOI Px

AntiretroviralsAdherence

Support

NationalHIV Program

NationalHIV Program

CommunicationCollaboration

TB Services

Sputum collectionDOT

Treatment SupportContact TracingLTBI Treatment

TB Services

Sputum collectionDOT

Treatment SupportContact TracingLTBI Treatment

HIV Services

PITCOI Px

AntiretroviralsAdherence

Support

National TB Program

Communication and

Collaboration

8

From DOTS to the Stop TB Strategy• High quality DOTS

expansion• TB/HIV, MDR-TB,

vulnerable populations• Health systems

strengthening, primary health care

• Engage all care providers• Empower TB patients,

communities through partnerships

• Research

8

9

Policy and Practice

TB Treatment Outcome• Cured• Treatment completed• Died• Treatment failure• Transferred out• Default

A. Establish NTP-NACP collaborative mechanisms Set up coordinating bodies for effective TB/HIV activities

at all levels Conduct surveillance of HIV prevalence among TB cases Carry out joint TB/HIV planning Monitor and evaluate collaborative TB/HIV activities

B. Decrease burden of TB among PLHIV (the "Three I's") Establish intensified TB case finding Introduce INH preventive therapy Ensure TB infection control in health care and congregate

settings

C. Decrease burden of HIV among TB patients Provide HIV testing and counselling Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy Ensure HIV/AIDS care and support Introduce ARVs

World Health Organization

Policy on collaborative TB/HIV activities A WHO Document, 2004

Lancet 2006; 368: 1575-80

TB Infection Control – 10 Steps• Involve community• Develop IC plan• Safe sputum collection• Cough hygiene• Triage TB suspects• Rapid diagnosis and treatment• Improve room ventilation• Protect health care workers• Capacity building• Monitor IC practices

Science 2010; 328:856

Game Changers

• Discontinuous, radical innovations completely changing the way something is done, thought about, or made. Examples:

- Cell phones - HIV/AIDS- Laptop computers - Antiretrovirals- Internet - PEPFAR- 9/11

Antiretroviral Therapy for HIV Prevention

• Transmission occurs only from HIV+ persons

• Viral load is strongest risk factor for transmission

• ART can lower viral load to undetectable levels

• PMTCT offers proof of concept of reduced transmission with ART

• Discordant couple studies are supportive

Discordant Couple StudiesReynolds S et al. 16th CROI, Montreal, Feb 2009 Abs. 52a

Marcelin A et al. 16th CROI, Montreal, Feb 2009 Abs. 51

Donnell D et al. Lancet 2010;375:2092-8

Antiretroviral therapy for HIV prevention

• Mathematical model of universal HIV testing annually with immediate ART for HIV+ in southern African epidemic

• 95% reduction in HIV incidence in 10 years

• Prevalence <1% in medium term

• Major reduction in mortality

• Cost-saving in medium termLancet 2009;373:48-57.

Trial of 6 vs 36 mos of isoniazid preventive therapy, Botswana

(Samandari T et al, 2009)

TB/HIV in High HIV Prevalence Settings

What will it take?• Evidence and data• Innovative and clear thinking• Judgment - balancing risk and “reckless

caution”• Leadership• Policy, linked to research, implementation and

advocacy