Policy review of HIV and TB
guidelines for high HIV/TB burden
African countries
HIV/AIDS Department
World Health Organization
WHO 2010 ART guidelines
Target Population
ART guideline
HIV+ asymptomatic patients
ARV-naïve individuals
CD4 < 350 cells/mm3
HIV+ pregnant women
CD4 < 350 cells/mm3 irrespective of
clinical symptoms or WHO clinical
stage 3 or 4 irrespective of CD4 cell
count
HIV/TB co-infection
ARV- naïve individuals
Presence of active TB, irrespective
of CD4 count
WHO 2004 Interim Policy on
Collaborative TB/HIV Activities
A. Establish NTP-NACP collaborative mechanisms
 Coordinating bodies for effective TB/HIV activities at all levels
 Conduct surveillance of HIV prevalence among TB cases
 Carry out joint TB/HIV planning
 Monitor and evaluate collaborative TB/HIV activities
B. Decrease burden of TB among PLHIV (the "Three I's for HIV/TB")
 Establish intensified TB case finding
 Introduce INH preventive therapy
 Ensure TB infection control in health care and congregate settings
C. Decrease burden of HIV among TB patients
 Provide HIV testing and counselling
 Introduce HIV prevention methods
 Introduce co-trimoxazole preventive therapy
 Ensure HIV/AIDS care and support
 Introduce ARVs
WHO 2010 IPT/ICF Recommendations
 Use of four-symptoms screening algorithm to rule out
active TB and offer IPT
 Four symptoms include cough, fever, weight loss and
night sweats
 Past history of TB and current pregnancy should not be
contraindications for IPT
 TST or chest radiography are not required
Estimated 2009 HIV/TB and HIV burden
Country
People with
HIV-Figure in
'000 (% of
global HIVpositive
people)
People with
HIV and TBFigure in '000
(% of global
HIV/TB
burden)
People
eligible for
ART at
CD4 < 350
cells ('000)
People on
ART ('000)
ART
coverage
(%)
People
living with
HIV
screened
for TB
('000)
ART
coverage
(%)
320 (1.0)
6.8 (0.6)
170
145.2
83
159.1
11700
N/A
34 (2.8)
N/A
176.6
N/A
24.1
2403
Kenya
1500 (4.5)
53 (4.4)
710
337
48
14.1
N/A
Lesotho
290 (0.9)
8.7 (0.7)
130
61.7
48
N/A
N/A
Malawi
920 (2.8)
27 (2.3)
440
198.8
46
N/A
N/A
Mozambique
1400 (4.2)
54 (4.5)
570
170.2
30
24.3
2429
Namibia
180 (0.5)
9.2 (0.8)
93
70.5
76
87.5
17700
Nigeria
3300 (9.9)
87 (7.3)
1400
303
21
195.1
1853
5600 (16.8)
290 (24.2)
2600
971.6
37
433.7
23600
Swaziland
180 (0.5)
10 (0.8)
80
47.2
59
8.4
2107
Tanzania
1400 (4.2)
38 (3.2)
660
199.4
30
5.5
153
Uganda
1200 (3.6)
54 (4.5)
520
200.4
39
57.7
N/A
Zambia
980 (2.9)
23 (1.9)
440
283.9
64
N/A
N/A
Zimbabwe
1200 (3.6)
48 (4.0)
640
218.6
34
N/A
N/A
Total
18470 (55.5)
742.7 (61.9)
8453
3384.1
38
1009.5
61945
Botswana
Ethiopia
South Africa
Source : 2010 Stop TB global surveillance report, UNAIDS Report on global AIDS Epidemic 2010
Objectives and Methodology
Objectives:
Compare national HIV, TB and HIV/TB guidelines for 14 African countries with
recently released WHO ART and HIV/TB guidelines
Methodology:
Main guidelines were collected from the following sources:
 National HIV Guidelines
 National TB Guidelines
 HIV/TB and TB infection control Guidelines
Standard abstraction form was used to review recommendations on:
 ART initiation criteria
 The Three I’s for HIV/TB
 The Three I's for HIV/TB monitoring and evaluation indicators
Source : National HIV, TB and HIV/TB
Guidelines
Country
National ART
guidelines
National TB control
guidelines
Botswana
2008
2007
Ethiopia
2008
2008
2007
Kenya
2011
2009
2008
Lesotho
2007
2008
Malawi
2011
2007
2008
Mozambique
2010
2008
2010
Namibia
2010
2011
2010
Nigeria
2010
2010
2008
2008
South Africa
2010
2008
2010
2007
Swaziland
2010
2010
2011
2011
Tanzania
2009
2006
Uganda
2008
2010
2006
2011
Zambia
2010
2008
2010
Zimbabwe
2010
2010
2010
* Published guidelines, Drafts, Preliminary drafts
HIV/TB, ICF, IPT,
OI guidelines
TB infection
control guidelines
ART initiation criteria in people with HIV
Country (Year of publication
of ART guidelines)
Asymptomatic
people
People with HIV and TB
Pregnant women
Botswana (2008)
<250
Irrespective of CD4 count
<250
Ethiopia (2008)
<200
<350
<200
Kenya (2011)
<350
Irrespective of CD4 count
<350
Lesotho (2007)
<350
<350
<350
Malawi (2011)
<350
Irrespective of CD4 count
Irrespective of CD4 count
Mozambique (2010)
<250
<350
<350
Namibia (2010)
<350
Irrespective of CD4 count
<350
Nigeria (2010)
<350
Irrespective of CD4 count*
<350
South Africa (2010)
<200
<350
<350
Swaziland (2010)
<350
Irrespective of CD4 count
<350
Tanzania (2009)
<200
<350
<200
Uganda (2008)
<250
<350
<350
Zambia (2010)
<350
<350
<350
Zimbabwe (2010)
<350
Irrespective of CD4 count*
<350
All figures in cells/mm3, Guidelines in white are similar to WHO recommendations.
* Nigeria's TB and HIV/TB guidelines and Zimbabwe's HIV/TB guidelines recommend ART for people with HIV and
TB at CD4 count < 350 cells/mm3
ART initiation for asymptomatic people
2010 WHO Recommendation : CD4 count < 350 cells/mm3
≤ 350
Kenya, Lesotho, Malawi, Namibia, Nigeria,
Swaziland, Zambia, Zimbabwe
≤ 250
Botswana, Mozambique, Uganda
≤ 200
Ethiopia, South Africa, Tanzania
CD4 Count
ART initiation for people with
HIV and TB
2010 WHO Recommendation : ART irrespective of CD4 count
Irrespective of
CD4 count
CD4<350 cells
Botswana
Ethiopia
Kenya
Lesotho
Malawi
Mozambique
Namibia
South Africa
Nigeria
Tanzania
Swaziland
Uganda
Zimbabwe
Zambia
• Zambia recommends ART at CD4 count > 350 cells/mm3 if any other stage III or IV illnesses
• Ethiopia recommends ART for all extrapulmonary and disseminated TB patients
ART initiation for pregnant women with HIV
2010 WHO Recommendation : CD4 count < 350 cells/mm3
Irrespective of
CD4 count
CD4<350 cells
CD4<250 cells
CD4<200 cells
Malawi
Kenya
Botswana
Ethiopia
Lesotho
Tanzania
Mozambique
Namibia
Nigeria
South Africa
Swaziland
Uganda
Zambia
Zimbabwe
• Malawi, under Option B+, recommends lifelong ART for all pregnant women
irrespective of CD4 count
Co-trimoxazole prophylaxis
2006 WHO Recommendation : CD4 count < 350* cells/mm3 or WHO stage 3 or 4
CD4< 200 Cells or WHO
Stage 3 or 4
Botswana
All HIV positives
CD4< 200 Cells or WHO
Stage 2, 3 or 4
Kenya, Malawi,
Swaziland
South Africa
Different guidelines followed
by different countries
CD4< 350 Cells or WHO Stage
2, 3 or 4
CD4< 250 Cells or WHO
Stage 2, 3 or 4
Mozambique, Tanzania,
Zambia, Ethiopia**, Zimbabwe
Uganda
CD4< 350 Cells or WHO
Stage 3 or 4
Lesotho, Namibia,
Nigeria
*Countries may choose to adopt a CD4 threshold of < 200 cells/mm3
**Source: Ethiopia's Co-trimoxazole prophylaxis guidelines, 2006
National policies for HIV, TB and
HIV/TB, and the Three I's for HIV/TB
Country
ICF
IPT
TB infection
control
Indicators on the
Three I's for HIV/TB
NAP
NAP, NTP
NAP, NTP
NTP
NAP, NTP, HIV/TB
NAP, NTP, HIV/TB
NTP, HIV/TB
HIV/TB
NAP, OI, NTP
NAP, OI, NTP
NAP, OI, NTP
x
Lesotho
NAP, NTP
NAP, NTP
NAP, NTP
NTP
Malawi
NAP, NTP
NAP, NTP**
IC
NTP
Mozambique
NAP, NTP
NAP, NTP
NAP, NTP, IC
NAP
Namibia
NTP
NAP, NTP
NTP, IC
NTP, IC
Nigeria
NAP, NTP, HIV/TB
NAP, NTP, HIV/TB
NTP, HIV/TB, IC
IC
NAP, NTP, IPT
NAP, NTP, IPT
NTP, IC
IPT
Swaziland*
NAP, IPT
NAP, IPT
NAP, IC
NAP, IPT, IC
Tanzania
NAP, NTP
NAP, NTP
NAP, NTP
x
Uganda
NAP, NTP, HIV/TB
NTP, HIV/TB
NTP, HIV/TB, IC
HIV/TB, IC
Zambia
NAP, NTP, ICF
NTP**, ICF
NTP
NTP
NTP, HIV/TB
NTP**, HIV/TB**
NTP, HIV/TB
x
Botswana
Ethiopia
Kenya
South Africa
Zimbabwe
NAP – National ART Policy, NTP – National TB Policy, ICF – National intensified TB case finding guidelines, IPT – National IPT
guidelines, IC – TB infection control guidelines, OI – National guidelines on management of HIV-related opportunistic infections
Note: * 2011 NTP for Swaziland recommends Three I's for HIV/TB but do not mention any guidelines
** These guidelines do not recommend IPT
Countries recommending the Three
I’s for HIV/TB
Country
ICF
IPT
TB infection control
Botswana
✓
✓
✓
Ethiopia
✓
✓
✓
Kenya
✓
✓
✓
Lesotho
✓
✓
✓
Malawi
✓
✓
✓
Mozambique
✓
✓
✓
Namibia
✓
✓
✓
Nigeria
✓
✓
✓
South Africa
✓
✓
✓
Swaziland
✓
✓
✓
Tanzania
✓
✓
✓
Uganda
✓
✓
✓
Zambia
✓
✓*
✓
Zimbabwe
✓
✗
✓
* Zambia: Preliminary draft on ICF guidelines recommends IPT
TB screening criteria for IPT
2010 WHO Recommendation : Symptom-based screening
Nigeria
Ethiopia
Uganda
LEGEND
IPT Initiation criteria
Kenya
Tanzania
Malawi
Symptom-based
Zambia
Zimbabwe
Namibia
Mozambique
Botswana
Symptom-based + sputum
smear microscopy + chest X-ray
Symptom-based + sputum smear
microscopy + chest X-ray + TST
Swaziland
South
Africa
IPT not recommended
Lesotho
Note: The map shows IPT initiation criteria recommended by the most recent guidelines for a country
TB exclusion criteria for IPT initiation
2010 WHO Recommendation : Four-symptom screening for cough, fever, weight loss and night sweats
KENYA
OI 2008
NIGERIA*** NTP 2009
NAP 2010
Chest
Sputum
X-ray
smear
WHO
recommendation
SOUTH AFRICA
IPT 2010
ETHIOPIA
HIV/TB 2008
Chest
X-ray
ZAMBIA
IPT 2010
MALAWI
NAP 2011
Night
sweats
Weight
loss
BOTSWANA
NAMIBIA* NTP 2007
NAP 2010
Enlarged
Diarrhoea
glands
UGANDA
NTP 2010
LESOTHO
NAP 2007
TST
Sputum
smear
Sputum
smear
Fever
Chest
X-ray
Cough
Cough
Chest
pain
SOUTH
AFRICA Coughing
blood
NAP 2010
MOZAMBIQUE
NAP 2010
Enlarged
glands
KENYA
TANZANIA** NAP 2011
NAP 2009
SWAZILAND
Abnormal
Swelling
NAP 2010
chest
findings
Chest
Chest
Coughing
Coughing
blood
Sputum
production
Chest
pain
Chest
pain
Loss of
appetite
Loss of
appetite
Loss of
appetite
pain
blood
pain
Shortness
of breath
Shortness
of breath
Shortness
of breath
Night
sweats
Night
sweats
Night
sweats
Night
sweats
Night
sweats
Night
sweats
Enlarged
lymph
nodes
Enlarged
lymph
nodes
Night
sweats
Weight
loss
Weight
loss
Weight
loss
Weight
loss
Weight
loss
Weight
loss
Weight
loss
Night
sweats
Fever
Fever
Fever
Fever
Fever
Fever
Fever
Fever
Cough
Cough
Cough
Cough
Cough
Cough
Cough
Cough
Cough
Chest
X-ray
* 2011 TB guidelines for Namibia recommend enlarged lymph nodes as an additional symptom
** 2006 TB guidelines for Tanzania recommend chest pain as an additional symptom
*** 2008 IPT guidelines for Nigeria recommend weight loss as an additional symptom, 2010 NTP guidelines do not recommend chest X-ray and
sputum smear microscopy
Exceptions to WHO
recommendations on IPT
2010 WHO Recommendation : IPT to all irrespective of previous
history of TB or current pregnancy and IPT with ART also
recommended
1.
Botswana and Mozambique – No IPT initiation in pregnancy
2.
Botswana and Tanzania – IPT not for children
3.
South Africa – IPT with ART is a conditional recommendation
4.
Lesotho – IPT offered to TB-exposed HIV infected children and at pilot sites
where active TB can be ruled out
5.
Malawi – Stop IPT when patient is started on ART
6.
Kenya and Swaziland– IPT provided in clinics with TB screening,
adherence counselling and patient follow-up services
7.
Uganda – IPT provided in institutions with adequate human resources,
infrastructure, and equipment and logistics
Indicators for monitoring and evaluating
performance on the Three I’s for
HIV/TB
ICF
Yes
IPT
No
Yes
No
Lesotho
Botswana
Botswana
Kenya
Ethiopia
Kenya
Ethiopia
Malawi
Malawi
South Africa
Lesotho
Nigeria
Mozambique
Tanzania
Mozambique
Tanzania
Namibia
Zimbabwe
Namibia
Zambia
Nigeria
South Africa
Swaziland
Swaziland
Uganda
Uganda
Zambia
Malawi, Namibia, Nigeria, Swaziland and Uganda have indicators for TB
infection control
Limitations
Guidelines may be outdated and/or in the
process of being updated
Written policies may not reflect programme
implementation
Other guidelines covering ART and the Three I’s
for HIV/TB may exist

- Infection control guidelines
- Monitoring and evaluation guidelines
Conclusion
•
Many countries follow the recently released WHO guidelines
- Asymptomatic patients – 8 countries
- HIV/TB co-infected people – 7 countries
- Pregnant women – 10 countries
•
Malawi recommends lifelong ART for pregnant women irrespective of
CD4 count (Option B+)
•
Almost all countries have recommendations on the Three I’s for HIV/TB
•
CPT initiation criteria differs widely across countries
•
ICF and IPT guidelines specified in both NAP and NTP for many
countries
•
Many countries have ICF and IPT indicators
•
Room for improving monitoring and evaluating progress on TB infection
control
Recommendations
ART policy

Revise ART eligibility criteria where necessary
IPT policy

Adapt policies to recommend IPT for all, including pregnant
women, previous TB patients and PLHIV on ART

Simplify criteria for IPT initiation
Monitoring and evaluating of the Three I's for HIV/TB

Include indicators on ICF and IPT in National ART Guidelines

Adapt and implement indicators for TB infection control
Thank you…