Embed Size (px)
Citation preview
Review of the Last Decade:
From Where to Where?
Diane Havlir, MD
Professor of Medicine
University of California, San Francisco
Chair, TB/HIV working group, WHO
2004 – the way we were
HIV/TB working group– what we did
2014 – the way we are
Towards 2024
2004: The Way We Were
Opportunity lands on Mars Bird Flu spreads across
10 Asian Countries
Ukranian elections
trigger political crises Brazil reigning World Cup Winner
2004: HIV/TB running rampant
with little fanfare
Rapid, unabated increase in TB
caseload due to HIV/TB interaction
Karim, Lancet, 2009
Stone Age Tools and Lack of
Knowledge
Diagnostics – still relying on
PPD and smear!!
• Curtailed implementation of IPT
• Contributed to missing active TB
cases that led to death
Treatment– long courses,
drug stock outs
MDRTB– clueless on
frequency and magnitude of
problem
Unknown when to start ART
Unknown drug interactions
between ART and TB
Neglected infection control
Major chasms in communication
between HIV and TB
Global Level- UNAIDS, WHO, IAS, PEFAR
Country Level– Separate program leadership HIV
and TB
Local Level- Separate HIV and TB programs
Advocacy– Strong in HIV, weak in TB, no HIV-TB
Research- No forum or focus on HIV-TB, parallel
and disconnected discussions at HIV and TB
meetings
Funding– Lack of targeted HIV-TB focus
Evidence that implementation was
failing
Only 7% HIV
testing among
persons with TB !
o o
o
o
o
o
oo ooo
oo
oo
oo
o
o
o oo
o
oo
o
o
oo
o
o
o oo
o
oo
oo
oo
o
oo
oo
o
o
o
o
o
oo
o
o
o
o
o
o
• 25,000 persons on IPT
• 0.4 % persons with HIV screened for TB
• Detection of only 14% HIV/TB cases
No report
< 15%
15-24%
25- 50%
50+%
2005 Data
What we did: HIV/TB Working
Group Strategy
Create visibility for HIV/TB at global level
Convene: Forum to bring stakeholders together
Advise guidelines and dissemination
Promote Research
Catalyze implementation
Activism Science Convener
Political Stage
2004 Mandela urges action on TB,
IAC, Bangkok
2009- Clinton at HIV/TB Global
Leaders Forum
2009-Sampaio HIV/TB Global
leaders forum
2012– Clinton urges political
leadership on HIV/TB
“To fight AIDS we must do more to fight TB”
Forging Partnerships– MOU
UNAIDS and Stop TB
Plan signed in July 2011
Target to reduce TB related HIV deaths by half by 2015.
Instrumental to catalyse implementation and garner support from HIV community
US Government leading the way
Ambassador Dybul-- 50 million dollar targeted
funding to HIV/TB; speaking at International AIDS
conference on HIV/TB in Mexico City,
Ambassador Goosby- HIV/TB as a priority
initiative including as focus in PEPFAR blueprint-
“Creating an AIDS free generation.”
Deborah Birks– Nominated!!
Thank you USG HIV/TB technical working group
(CDC, USAID, OGAC) !!!!!!!
Activism: “Living with HIV,
Dying of TB”
AIDS 2008, Mexico
Participants of the first TB/HIV Advocacy training workshop for HIV activists, Nairobi, July 2004
Visibility and Communication:
Research
2007– started highly successful CROI HIV/TB pre-
meeting research think tank
Increased visibility of HIV-TB in both HIV and TB
(Union) annual meetings with cross talk between
fields
Co-sponsored new award for Young Investigator
in HIV/TB in International AIDS conference
Plenary, Special sessions, more abstract
sessions, symposiums on HIV/TB at HIV
international conferences.
Capetown HIV/TB Research
Meeting Keynote address Tony Fauci
• “The consequences of inattention
to TB research are not just
embarrassing, they are tragic and
shameful. Generations of research
advances and technologies have
bypassed the field of TB research.
All of the great breakthroughs that
we have seen in molecular biology
- there was nobody working on it in
TB “
Great talks and discussions
First public presentation of
Xpert TB preliminary data by
FIND– standing ovation
Guidelines: The initial blueprint
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 PLWHA
B.1. Intensified TB case finding
B.2. Isoniazid preventive therapy
B.3. TB infection control
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
C.4. HIV/AIDS care and support
C.5. Antiretroviral therapy to TB patients.
WHO response : TB/HIV policy and
programme guidance
WHO 2010 ART Guidelines
• Provide IPT for HIV-
positive patients without
active TB
• For those with TB, ART
initiated as soon as
possible after the start of
TB treatment
• At 2 weeks when CD4<50;
no later than 8 weeks
• Do not delay ART
waiting for CD4+
count
HIV/TB guidance integrated into 2013 WHO
ART Consolidated Guidelines
Prevent TB
Reduce TB deaths
Global Fund and TB/HIV response
“GFATM’s guidelines for
proposal should stress the
importance of including TB
interventions in HIV proposals,
and vice versa, as a requirement
for successful applications from
high-burden TB/HIV countries.”
Recommendation of the Global
TB/HIV Working Group,
September 2004
Countries with high co-infection rates of TB and HIV shall submit a single concept note that presents integrated and joint programming
for the two diseases
(GF/SIIC09/DP6)
Decision of the Global Fund Board 2013
Workshops to Accelerate
Implementation
2004-Addis, address smear negative/DOTS metric
2007– Washington, DC. Acceleration implementation in
SSA, co-sponsored with PEPFAR
2009– Bangkok. TB/HIV/Advocacy persons using drugs
2010- Almaty, Central Asia focus including MDR TB,
incarcerated population
2011 Bejing, Addressing TB/HIV where HIV prevalence
relatively low
2011, Panama City Implementation HIV/TB in Americas
2013 Maputo, implementation and the care cascade
in SSA
This is only a partial list!
2014: The Way We Are
6.8 billion mobile phones
Ukraine in political
crises Brazil is hosting the World Cup
Global warming gets attention
2014: Evidence that implementation is
working…but not enough
Number of cases and deaths
Lives saved
IPT rollout
HIV testing of new TB cases
TB screening in persons living with HIV
The Big picture– Decline in HIV/TB
cases and decline in deaths
INH preventive therapy is increasing, but still less
than a 25% of persons in care are receiving it
Global TB report, 2012
For active TB, rates of HIV testing
dramatic increased
Global TB report, 2012
High HIV testing in TB in Africa, but
still signifcant gaps
Global TB report, 2012
Global TB report, 2012
Most TB patients receiving co-trimoxazole,
but less than half receiving ART
Global TB report, 2012
Global heterogeneity in ART access in TB
patients
Global TB report, 2012
1.3 Million lives saved with HIV/TB
interventions
Key scientific developments over
the last decade
Prevention studies– shorter
course, extended courses
Gene Xpert
Bedaquiline
Knowledge on when to start
ART in persons with TB
Knowledge on what ART to
start
Community level approaches
What has not changed
Diagnostics are still inadequate
Treatment falls short for many
Systems for care are often broken
People are still dying of HIV/TB
Launch IPT
Start ART by 2 weeks with active TB – and
monitor it!
Make HIV/TB activities “patient- centric”
What could be done… quickly
Towards 2024
Combination Prevention
New and Targeted Diagnostics
Delivery systems that match the population
New drugs- accessible to the population and
smart research studies
Eliminate HIV/TB deaths
Combination Prevention for
HIV/TB
ART is the most
important prevention
IPT compliments and
synergizes with ART
Transmission reduction
strategies
• Infection control
• Enhanced case finding
ART
IPT
Transmission
reduction
New Diagnostics in Functional
Systems
The era of molecular and
point of care testing is
now
Fix logistics to maximize
effectiveness of new
technology in the real
world
Integrate information
systems that facilitate
care delivery and
monitoring
Defining and Refining HIV/TB Care
Cascade…
… Tailored to the setting
General populations
• HIV clinics
• TB clinics
• Hospitals
• Rural outposts
• Private sector
Special populations
• Antenatal clinics
• Children
• Persons who use drugs
• Migrant populations
“So obvious, but so difficult”
…yet DOABLE!!!
Summary Remarks
Great progress has been made in HIV/TB over the
last decade
Working Group has contributed to that progress
There is still much to be done
There are untapped opportunities to intervene
that could have great impact that largely lie in the
implementation sphere and rethinking strategy
Political will and visibility, advocacy, research
will continue to be essential for progress
Thank you Global TB/HIV Working
Group!!
Bridge to end AIDS and
all HIV/TB deaths
Thank you to my family
2004 Almost 10 year later
