Christine Lubinski Vice President for Global Health Infectious Diseases Society of America

Christine LubinskiChristine LubinskiVice President for Global HealthVice President for Global Health

Infectious Diseases Society of AmericaInfectious Diseases Society of AmericaApril 17, 2009April 17, 2009

Germs Go GlobalGerms Go GlobalTuberculosis and HIV/TB Co-InfectionTuberculosis and HIV/TB Co-Infection

Global Tuberculosis PandemicGlobal Tuberculosis Pandemic• Second leading infectious disease killer worldwide

• One-third of the world’s population is infected

• 9.27 million new cases in 2007

• An estimated 1.37 million of these cases were HIV-positive• 79% of HIV+ cases in Africa

• 1.8 million deaths in 2007, including almost 500,000 among HIV infected persons

• 500,000 cases of MDR-TB in 2007

• By the end of 2008, 55 countries reported at least one case of XDR-TB

HIV/TB Co-Infection: Deadly Synergy• HIV infection facilitates active TB disease in those with latent TB

• IPT effective but not available to most in need

• HIV epidemic has amplified the TB epidemic in dual burden countries- expanded TB risk to thecommunity at large

• TB is the leading cause of death among persons with HIV

• TB undermining US efforts to save lives from AIDS in Africa

• TB expedites HIV disease progression

• TB patients continue to have limited ART access

• TB is more difficult to diagnose in persons with HIV and is also more challenging to treat

Estimated Tuberculosis Incidence Rates, Estimated Tuberculosis Incidence Rates, by Country, in 2007by Country, in 2007

Estimated HIV Prevalence in new Estimated HIV Prevalence in new Tuberculosis cases in 2007Tuberculosis cases in 2007

Tuberculosis: Antiquated tools forTuberculosis: Antiquated tools for diagnosis, diagnosis, treatment and preventiontreatment and prevention

Diagnostics-• Detect only half of people tested and fewer than 20% of HIV patients with active TB

• Tests for drug resistant strains not available in most of the developing world

Drugs- • 4 drugs must be taken for 6-9 months– significant side effects, not compatible with important anti-HIV drugs

• Drug resistant TB requires 2 years of treatment with highly toxic drugs, which are frequently not available indeveloping countries

Vaccine- • existing vaccine does not protect past infancy, and is not recommended in infants with HIV infection

Tuberculosis Research & DevelopmentTuberculosis Research & Development

• $482.5 million spent worldwide in 2007, far short of WHO goals of $900 million per year

•TB drugs received highest level of funding at $170 mil

• US diagnostic research is grossly underfunded at $41.9 million, as is operational research at $36.8 million

• Top Funder– NIAID/NIH at $160 million

• No.2 funder– Bill & Melinda Gates Foundation at $124 million in 2007. Gates Foundation funding outpaced NIH in all categories except for basic research

Treatment Action Group: TB Research and Development: A Critical Analysis of Funding Trends, 2005-2007 An Update

Tuberculosis in the United StatesTuberculosis in the United States

Over the last 3 years, more than 1000 jobs have been lost

in state TB control programs

Progress toward TB elimination has slowed down

12,898 new cases were reported in 2008

125 cases of MDR-TB

58% of cases were foreign born; Among US-born populations

blacks have TB rate 7 times higherthan whites

Annual CDC TB Budget, FY 1990Annual CDC TB Budget, FY 1990––FY 2008FY 2008 (2008 budget 40% lower than 1994, in CPI-Adjusted dollars*) (2008 budget 40% lower than 1994, in CPI-Adjusted dollars*)

* Adjusted to 1990 dollars by Consumer Price Index for Medical Care, includes TB/HIV and lab dollars

$0

$50

$100

$150

$200

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Bud

get (

$ x

mill

ion)

Actual $

CPI-Adjuste

d

Source: Center for Disease Control and Prevention

New Legislative Authorities*New Legislative Authorities*

*Not yet appropriated

Comprehensive TB Elimination Act:

• $200 million for TB prevention, control, and new tools FY 2009-2013

Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act:

• $4 billion for global TB prevention FY 2009-2013

Fund the Comprehensive TB Elimination Act : Fund the Comprehensive TB Elimination Act : Public Law 110-392Public Law 110-392

• Authorizes $200 million for TB prevention, controland new tools FY 2009-2013

• Shore up state TB control programs

• Enhance US capacity to address drug-resistant TB

• Facilitate development of new “tools”- drugs, diagnostics, vaccines

• Current TB funding is inadequate for testing diagnostics, drugs, and vaccines currently in pipeline in Phase III trials

Advancing TB R&D and Global TB ControlAdvancing TB R&D and Global TB Control• Double TB research Spending to $320 million at NIH, providing resources for clinical trials, diagnostics and research agenda for drug-resistant TB

• $100 million for CDC TB R & D

• Provide $2.7 Billion to the Global Fund– largestfunding of global TB control

• Enhance USAID TB Spending to $650 million toImplement Lantos/Hyde

• Increase operational research through USAID and OGAC

• Implement recommendations of the Federal TBTask force to respond to MDR-TB domesticallyand globally

HIV/TB: US ResponseHIV/TB: US ResponseFund Lantos-HydeFund Lantos-Hyde

•Continue scale-up of HIV treatment, which reduces TB morbidity/mortality in PWHIV

•Fund the Global Fund to Fight HIV, TB and Malaria at $2.7 billion- leading global funder of TB control.

•Ensure that TB screening, treatment and preventive therapy are standard of care at PEPFAR-funded HIV clinics

•Stop TB transmission in HIV clinics by Implementing infection control strategies

Crisis in Antimicrobial ResistanceCrisis in Antimicrobial Resistance

Antimicrobial-Resistant Strains Spread Rapidly

MRSA = methicillin-resistant Staphylococcus aureus; VRE = Vancomycin-resistant enteroccoci; FQRP =Fluoroquinolone-resistant Pseudomonas aeruginosa

Source: Centers for Disease Control and Prevention

Strategies to Address Antimicrobial

Resistance (STAAR) ActTo Strengthen Federal Antimicrobial Resistance Surveillance, Research and Prevention & Control

Working TogetherWe Can Enact the STAAR

Act!!

IDSA’s 2004 Report: “Bad Bugs, No Drugs (BBND): As Antibiotic Discovery Stagnates, A Public Health Crisis Brews”

“Only 16 new antibacterials are in late-stage clinical development at this time.” -- Bad Bugs, No Drugs: No ESKAPE! An Update from the Infectious Diseases Society of America (Clinical Infectious Disease 2009:48; January 1, 2009)