TB/HIV Research Priorities in Resource-Limited Settings

Where we are now and some suggestions for where to go

Paul Nunn14-15 February 2005

Contents of Presentation

• Current context– TB and HIV epidemics and overlap– Status of analytical and policy response

• Definitions

• Suggested approaches

• Conclusions

Current Global Status

• 8.8 million new cases in 2003 – 7.6% of total cases HIV+ (674 000) = 12% of

adult cases

• TB notifications and estimated incidence decreasing in 5 WHO regions, increasing in Africa

• Global estimated incidence grew 1%• Prevalence and mortality rates falling• 3% of TB cases tested for HIV

Epidemic in sub-Saharan Africa Epidemic in sub-Saharan Africa 19851985−−2003 2003

0

5

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1985198619871988198919901991199219931994199519961997199819992000200120022003

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ions

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% HIVprevalence adult (15-49)

Number of people living with HIV and AIDS

% HIV prevalence, adult (15-49)

Year

Source: UNAIDS/WHO, 2004

2004 Report on the Global AIDS Epidemic (Fig 5)

TB/HIV in Africa – 2002

• Total cases annually in SSA 2.35m• Cases notified annually in SSA 996k• Estimated no. of notified HIV+ 243k• Number (%) HIV + 596k (25%)• % Adult TB patients HIV+ 37%• Deaths from TB due to HIV 207k• % of HIV deaths due to TB 15%• Treatment success 73% (average

82%)

Regional TB incidences

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50

100

150

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1980 1985 1990 1995 2000

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ions

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FSU

TB/HIV policy guidance - 2004

Interim policy M&E Surveillance ART

ProTEST lessons TBHIV Clinical HIV testing policy

Where are we now?

• Global consensus around TB/HIV interim policy• As yet, low dissemination of policy• Slow country level implementation of joint

TB/HIV activities– Some technical approaches undefined eg TB/HIV for

IDU– Low awareness of what needs to be done and how– Operating in the context of weak health systems

• Lack of human resources • Competing priorities: DOTS expansion, ARV scale up etc• "Money, money everywhere, but not a drop to spend" etc

Suggested Definitions

TB/HIV research in resource-limited settings:• Research aimed at improving the care of people with

HIV-associated TB in resource limited settings• Research aimed at improving the prevention of HIV-

associated TB• Research within the domain of "TB/HIV" – the additional

things TB programmes and AIDS programmes need to do to address the TB/HIV overlap

• Research aimed at improving TB/HIV control policies (health systems and policy research)

• Research aimed at improving operations of HIV and TB control (operational research or targeted evaluation)

TB/HIV research definition continued• It therefore includes health policy, health

systems and operational research that address TB/HIV;

• And also, new tools development that addresses the particular problems of the coinfected, eg TB diagnostics for those with HIV, ARVs compatible with rifampicin;

• And also clinical trials that answer operational questions in TB/HIV eg when should HIV+ TB patients start ARVs?

TB/HIV research definition concluded• We do not include research that

specifically addresses TB or HIV issues, with no particular reference to the TB/HIV overlap eg development of new drugs for TB, ways of counselling and testing for HIV to decrease HIV transmission, etc

• We have not included basic research, as not being focused on resource-limited settings

• A suggested approach

Three levels of research

• Research to answer specific technical questions eg does cotrimoxazole preventive therapy add protection to ARVs?

• Research to address how technical interventions can alleviate burden of TB/HIV, and how much (health systems research)

• Research to evaluate the whole TB/HIV package – analogous to the multi-country evaluation of IMCI

The rationale for health systems research for TB/HIV• TB/HIV depends strongly on TB and HIV/AIDS

control• TB and HIV/AIDS control severely limited by

weak health systems – and evidence base on health systems is also weak

• Many of the research questions in background papers are about how to implement TB/HIV activities within health systems

• The cross-cutting topics in agenda address the interaction between TB/HIV and health systems

Policy-maker's Questions Lavis J et al. Use of research to inform public policymaking. Lancet 2004;364:1615-21

• What is the best solution to the TB/HIV problem?– What is the overall benefit of implementing the TB/HIV policy

package, and how much does it cost, relative to the other interventions we are, or could be doing?

• What are the best ways to implement activities to solve the TB/HIV problem in my health system?– What governance, financial and delivery arrangements are the

most conducive to the effectiveness of the package, in our setting?

• How can I bring about the necessary changes in the health system to implement TB/HIV activities?– What informational, educational and financial (incentive)

approaches are needed to change behaviours to implement the package?

Assessment of the TB/HIV package• We need to demonstrate success/failure

– Whether it can/cannot be implemented (process indicators)– Whether it has/has not impact (impact indicators)– We need to show where it fails, so as to improve it, and avoid

wasting time and resources

• We need to do it fast, so that we encourage more rapid implementation (if we show it works)

• Therefore we need to build assessment into implementation– TB/HIV annual survey of policy and practice– Revision of routine recording and reporting for TB– Additional "targeted evaluation"/operational research– How to record and report "HIV-side" activities?

• Just do it and evaluate, or more formal assessment?

What is expected of us at this meeting? • Develop the agenda of research priorities

• Then develop plans for implementation– Find financial support– Identify teams of countries/researchers able

and willing– Provide technical assistance– Advocate for TB/HIV research

Conclusions

• Reaching TB and HIV MDGs depends on improving TB and HIV control, especially in high HIV areas

• Improving control depends on improving health systems• International consensus around 12 point package of

TB/HIV collaborative activities• A way forward:

– Refine the best technical solutions– Define how they fit into complex, under-resourced health

systems– Once we have a list of priorities, we should look ahead to

• funding needs, • human resources,• advocacy