TB/HIV Monitoring and EvaluationFrom Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia-Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia "TB/HIV Monitoring

From Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia-

Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia

"TB/HIV Monitoring and Evaluation"

This talk will introduce the WHO PEPFAR UNAIDS

agreed revision of TB/HIV collaborative indicator guide

HIV recording and reporting for HIV/TB

Christian Gunneberg M.O. STB

World Health Organisation, Geneva



I will address

• The revision of the TB HIV indicators

• The case for better integration of TB and

HIV monitoring,

• How collaborative TB HIV activities have

led to the revision of global estimates



2004 guide to Collaborative TB HIV activities



Revision of TB/HIV indicators

• Issues:

Original M&E guide 2004

Revision of WHO TB and HIV R&R

include TB/HIV data

• PEPFAR and UNGASS have own indicators

• Indicator harmonisation needed for countries

• Global Fund wanted to update their M&E toolkit



Harmonized indicators for the HIV/TB

• Revised TB/HIV indicator guide

• Harmonized

– WHO, UNAIDS, GLOBAL FUND,

& PEPFAR

• Aligned with WHO generic

recording and reporting formats

• Essential for monitoring of 3 Is

• New

– 13 instead of 20 indicators

– 2 Infection control indicators



% HIV STATUS

KNOWN

TB/HIV CASE

DETECTION

ART

PROVISION

CPT

PROVISION

FREE

CONDOMS

% HIV +ve

% TB/HIV

in HIV CARE



TB STATUS AT

LAST VISIT

STARTED TB

TREATMENT

HEALTH WORKERS

WITH TB

NEWLY ENROLLED

ON IPT

INFECTION

CONTROL

PRACTICES

CASE DETECTION

(UNGASS 6)



– TB status assessment

– TB treatment provision

– IPT provision

• On HIV patient forms

• On HIV Pre ART & ART Registers

• On quarterly cross-sectional reporting forms

Revision of HIV recording and reporting

formats to measure TB/HIV indicators

AIMS: report on



Progress in TB/HIV indicator reporting

by HIV programmes in Asia Pacific

0110000 111618

20

01

1

339

17

02

2

3311

19

49

10

8712

22

5

9

12

54

12

24

-

20

40

60

80

100

120

Tested for HIV HIV-positive CPT ART Screened for

TB

Diagnosed

with TB

IPT

Th

ou

sa

nd

s o

f p

atie

nts

2002

2003

2004

2005

2006

2007

Diagnosis and treatment of HIV in TB patients Diagnosis, treatment and prevention of TB

in people with HIV

Collaborative TB/HIV activities, 2002–2007,

WESTERN PACIFIC REGION

Western Pacific Region

(of 36)

0000000 0002222 0000111 01

1

11

4

3

1

2

2

43

5

5

1

4

4

55

6

5

-

20

40

60

80

100

120

140


TB

Diagnosed

with TB

IPT

Th

ou

sa

nd

s o

f p

atie

nts

2002

2003

2004

2005

2006

2007


in people with HIV

Collaborative TB/HIV activities,

2002–2007, SOUTH EAST ASIA REGION

South East Asia Region

(of 11)

0000000 0002222 0000111 01

1

11

4

3

1

2

2

43

5

5

1

4

4

55

6

5

-

20

40

60

80

100

120

140


TB

Diagnosed

with TB

IPT

Th

ou

sa

nd

s o

f p

atie

nts

2002

2003

2004

2005

2006

2007


in people with HIV

Collaborative TB/HIV activities,

2002–2007, SOUTH EAST ASIA REGION

0110000 111618

20

01

1

339

17

02

2

3311

19

49

10

8712

22

5

9

12

54

12

24

-

20

40

60

80

100

120


TB

Diagnosed

with TB

IPT

Th

ou

sa

nd

s o

f p

atie

nts

2002

2003

2004

2005

2006

2007


in people with HIV

Collaborative TB/HIV activities, 2002–2007,

WESTERN PACIFIC REGION



PRE/ART registers already contain TB tx

and IPT columns

• Adjust to record month year & TB registration numbers

• Now also to record TB status at monthly/quarterly visits



Pre-ART register:

TB status follow up



ART Registers

TB status at last visit.



Cross-sectional quarterly report

IPT

TB SCREENING

TB TREATMENT



The HIV/TB M&E Challenge:

Health facility implementation

ART services

TB treatment and HIV testing services

Country Level

PLHIV to be on pre ART register

& receive HIV care (ICF/IPT/CPT) here



Routine HIV testing of TB Patients

&

Revision of the TB/HIV Estimates



In all types of HIV epidemics,

health care providers should

recommend HIV testing and counselling

as part of the standard of care to:

− all adults, adolescents or children who

present to health facilities with signs,

symptoms or medical conditions that could

indicate HIV infection. These include

tuberculosis and other conditions specified

in the WHO HIV clinical staging system.

http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf

WHO recommendations 2007:



No reported activity

< 15%

15 to 50%

51 to 75%

More than 75%

Proportion of TB patients

tested for HIV

Key

2004 2005

2006 2007

12% 16%

Progress of HIV testing for notified TB patients Global

3% 9%



No reported activity

< 15%

15 to 50%

51 to 75%

More than 75%

Proportion of TB patients

tested for HIV

Key

2005

1.9%

Progress of HIV testing for notified TB patients Asia Pacific (47)

2006

2007

0.3%

6.0%

3.7%

2004 18

27

29

0.2 of 3.1 million notified TB patients

were tested in ASIA PACIFIC REGION in 2007



ASIA PACIFIC 2007

Proportion of TB patients with known HIV status

Country

Proportion TB

patients with HIV

status know 2007

Proportion of estimated

Regional TB HIV in 2007

(90% in 14 countries)

Proportion of

estimated TB HIV

cases reported as

detected in 2007Thailand 69% 8% 49%

Japan 64% 0.1% 60%

Malaysia 60% 2% 37%

Australia 41% 0.02% 37%

Cambodia 39% 3% 53%

Viet Nam 15% 6% 5%

Lao PDR 11% 0.15% 53%

Sri Lanka 6% 0.005% 21%

India 5% 52% 9%

China 3% 13% 5%

Myanmar 2% 5% 10%

Papua New Guinea 1% 1% 1%

Indonesia 0.10% 8.1% 1%

Philippines 0.03% 0.4% 0%

Country

Proportion TB

patients with HIV

status know 2007

Proportion of estimated

Regional TB HIV in 2007

(90% in 14 countries)

Proportion of

estimated TB HIV

cases reported as

detected in 2007Thailand 69% 8% 49%

Japan 64% 0.1% 60%

Malaysia 60% 2% 37%

Australia 41% 0.02% 37%

Cambodia 39% 3% 53%

Viet Nam 15% 6% 5%

Lao PDR 11% 0.15% 53%

Sri Lanka 6% 0.005% 21%

India 5% 52% 9%

China 3% 13% 5%

Myanmar 2% 5% 10%

Papua New Guinea 1% 1% 1%

Indonesia 0.10% 8.1% 1%

Philippines 0.03% 0.4% 0%



HIV testing and treatment, 2007

Region TB patients

tested for HIV,

thousands (%)

% of tested TB

patients HIV +

% of identified

TB patients on

CPT

% of identified

TB patients on

ART

AFR 492 (37) 51 66 29

AMR 114 (49) 13 36 77*

EMR 4.2 (1.1) 12 35 65*

EUR 169 (35) 2.5 52 16

SEAR 122 (5.5) 15 37 17

WPR 95 (6.6) 7 45 28

Global 996 (16) 30 63 30

Access to ART is very low and showed regional variation



64 countries with empirical data in 2007

• From national surveys of HIV in TB

– 7 countries (up from 2 last year)

• From sentinel surveillance systems

– 8 countries

• From routine testing (where tested / new

cases greater than 50%)

– 49 countries (up from 13 last year)



TB HIV estimates

What has changed?

• Significant upward revision

in 2007 HIV-TB estimates:

Better direct data

– Number of cases double

– 1.37m incident TBHIV cases in 2007,

Previous estimate (2006): 0.7m

– Number of deaths double

– 23% of estimated HIV deaths in 2007 had TB

456,000 TBHIV deaths / 2m HIV deaths



Conclusion and next steps

• Collaborative activities have improved

surveillance

• Need to enhance TB HIV M&E

– HIV testing of TB patients

– TB analysis from HIV registers

– e.g. better TB surveillance data from HIV care

TB/HIV Monitoring and EvaluationFrom Mekong to Bali: The scale up of TB/HIV collaborative activities in Asia-Pacific, August 8-9, 2009 Denpasar, Bali, Indonesia "TB/HIV Monitoring

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