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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
World Health Organization
Western Pacific Region
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 √
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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)
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
First First Regional Regional TB-HIV TB-HIV
FrameworFramework k
20042004
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
?
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific 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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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.
World Health Organization
Western Pacific Region
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.
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
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
World Health Organization
Western Pacific Region
• 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