TB/HIV Research Priorities in ResourceLimited Settings
Where we are now and some
suggestions for where to go
Paul Nunn
14-15 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
Millions
Epidemic in sub-Saharan Africa
1985−2003
30
30
25
Number of people living with HIV and AIDS
% HIV prevalence, adult (15-49)
25
20
20
15
15
10
10
5
5
0
0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Source: UNAIDS/WHO, 2004
2004 Report on the Global AIDS Epidemic (Fig 5)
% HIV
prevalence
adult (15-49)
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%)
250
Case notifictions/100,000 pop
Regional TB incidences
200
SSA
150
100
FSU
50
rest of world
0
1980
1985
1990
1995
2000
TB/HIV policy guidance - 2004
Interim policy
ProTEST lessons
M&E
TBHIV Clinical
Surveillance
HIV testing
policy
ART
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 resourcelimited settings:
• Research aimed at improving the care of people with
HIV-associated TB in resource limited settings
• Research aimed at improving the prevention of HIVassociated 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