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The World Health Organization released new data Monday documenting some significant progress in the battle against HIV and TB. In a report on progress in reaching the Millennium Development Goals, the WHO says that HIV incidence is declining and TB treatment is improving.

Here are the details from WHO:

HIV/AIDS
From 2001 to 2008 new HIV infections worldwide declined by 16%. In 2008, 2.7 million people contracted the virus and there were 2 million HIV/AIDS-related deaths. In 2008, around 45% of the 1.4 million HIV-positive, pregnant women in low- and middle-income countries received antiretroviral therapy (ART) to prevent the transmission of HIV to their babies. More than 4 million people in low- and middle-income countries were receiving ART by the end of 2008 but that left more than 5 million untreated HIV-positive people in these countries.

Tuberculosis
Despite a rise in the number of new tuberculosis (TB) cases worldwide – due to an increase in population – more people are being successfully treated. TB mortality among HIV-negative people has dropped from 30 deaths per 100 000 people in 1990 to 21 deaths per 100 000 in 2008. However, HIV-associated TB and multidrug-resistant TB are harder to diagnose and cure.

Click here for the full report.

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This post is by Global Center Director Christine Lubinski.

Viet Nam was an fitting spot for last week’s meeting of the Stop TB Partnership Coordinating  Board, since the country’s anti-TB efforts demonstrate both the challenges and the potential for progress in  combating this deadly disease.

Viet Nam’s Vice Prime Minister and Minister of Health welcomed members of the Stop TB Partnership Coordinating Board and expressed pride about the pace of Viet Nam’s economic development, as it stands on the threshold of moving from status as a low-income country to a lower middle-income country.

Viet Nam is one of the world’s 22 high burden TB countries, with significant rates of HIV/TB co-infection that have  contributed to an increase in TB prevalence in young adults.  Viet Nam’s national TB manager outlined the dimensions of the TB problem in the nation, as well as the response that began with a nationwide expansion of DOTS coverage in the 1990s. That effort now includes responding to co-infection and officials have also started to address the 2.7 percent of TB cases that are drug-resistant.  The country just began providing treatment to multidrug-resistant TB patients in 2009 and still only reaches a fraction of those infected with deadly resistant TB disease.  He outlined a number of critical challenges that plague highburden developing countries:

  • Human resources—about 50 percent of TB district staff are brand new and require additional training
  • Inadequate regulation of  TB drugs in the pharmacy market, leading to self-medication
  • ART access for patients co-infected with HIV and TB has improved but remains inadequate.  The 3 Is—Isoniazid preventive therapy, intensified case-finding, and infection control–also need to be strengthened.
  • MDR-TB is an emerging threat and the supply mechanism for second-line TB drugs is insufficient
  • Addressing TB in  so-called “closed settings”—prisons and re-education centers–and the coordination of these institutions with the national TB program
  • Strengthening the role of civil society in TB  control
  • Monitoring and evaluation

The TB manager identified scaling up TB/HIV activities, the response to pediatric TB, and responding to TB human resource needs as key next steps.

Viet Nam’s national TB program hosted a site visit to the Hanoi Hospital on Tuberculosis and Lung Disease, as well as a district health center making great strides in TB control with a burgeoning migratory population moving to the Hanoi area from rural areas of the country.

Outside the Hanoi Hospital on Tuberculosis and Lung Disease

The hospital director described the hospital’s key role in patient care, training, scientific research and providing leadership to the network of 29 district level clinics and providers providing T B services.

Viet Nam treats TB patients for 8 months, with the first two months using the DOTS model at the clinic daily.  After this, patients are given several weeks of medication and must check in with health providers frequently. There are more than 5,000 TB cases a year in Hanoi, and in 2009, almost 12 percent of these cases were TB/HIV co-infection.  Only about half of the TB patients were actually tested for HIV, so the number of co-infected patients is likely to be higher.  The mortality rate among the co-infected patients is 21 percent.  Half of all deaths at this hospital occur among co-infected individuals.  Notably, only 45 percent of the co-infected patients have access to ART.  

Eligibility for ART in Viet Nam is a CD4 count of under 200 or clinical symptoms of WHO Stage IV HIV infection.  Officials hope to move to a CD4 count of 250 soon for ART eligibility and to generally improve access to ART for co-infected individuals.  They have been successful in providing ART to some HIV patients with pulmonary TB.  It is also worth noting the CD4 diagnostic capability is not available everywhere.

Not all TB services are free in Viet Nam.  Patients must pay for physician services, chest X-rays and medical care related to extra-pulmonary TB, which occurs much more frequently in persons living withy HIV infection.

A visit to a district health facility offered an inspiring picture of dedicated staff working to provide TB and HIV services to a growing population of migrants.   This center has substantially ramped up screening of HIV-infected persons for tuberculosis and now ensures that nearly 100 percent of  TB patients are screened for HIV infection. The staff have engaged peer educators in their work to support co-infected patients.  The majority of persons living with HIV infection are injection drug users and center’s staff were excited to report that they are now offering methadone – the first pilot program in north Viet Nam.  They credit donor support for their ability to respond to the multiple health care needs of this complex and vulnerable population.  That donor is PEPFAR. 

The clinic director identified the need for strong support from local political leaders and the engagement of community members as key ingredients of this successful program.

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This post is by the Global Center’s Rabita Aziz.
 
Dr. Luis Sambo, the World Health Organization’s Regional Director for Africa, spoke to global health professionals and African diplomats today at an event sponsored by the Center for Strategic and International Studies (CSIS), about progress made toward achieving goals in the Abuja Declarations made roughly a decade ago.
 
The first Declaration, signed in 2000 by many African heads of state,  made commitments to reduce prevalence and consequently mortality from malaria by 50 percent by 2010.  In a second Abuja Declaration, signed in April 2001, heads of states declared HIV/AIDS to be a matter of emergency.
 
African leaders resolved to place the fight against HIV/AIDS at the forefront of their respective national development plans, as well as consolidate the foundations for the prevention and control of the disease through a comprehensive, multisectoral strategy involving all development sectors of government.  The leaders pledged to take more responsibility for the HIV/AIDS response, while also calling for an increase of external resources. 
 
In addition, the Abuja Declaration removed all taxes, tariffs, and other economic barriers to access funding for HIV/AIDS related activities.  Leaders also pledged to allocate 15 percent of their annual budgets to the improvement of health sectors.  The Declaration called for improving the availability of medical products and technologies, as well as supporting the development of vaccines.
 
Sambo said not all of these goals have been achieved.  For example, African nations on average allocate 6 percent of their budget to health sectors, instead of the pledged 15 percent, due in part to budget deficits.
 
But he also noted many successes in the fight against HIV.  Since the Declaration, there has been an improvement in diagnostics, care and support, and prevention, and dramatically higher coverage of antiretroviral therapy. In 2002, only 2 percent of patients in need of treatment were receiving it; in 2008, that number jumped to 44 percent.  HIV prevalence has dropped from 5.8 percent to 5.2 percent, and the rate of new infections has declined by 25 percent in that timeframe.  And since 2004, the annual number of HIV-related deaths has fallen by 18 percent.
 
Sambo said much of these successes were achieved thanks to external funding mechanisms, such as PEPFAR and the Global Fund.  He stressed that Global Fund and PEPFAR funds made significant contributions to change lives and provide hope.  Sambo also expressed high hopes for President Obama’s new Global Health Initiative, and expects it to be a powerful initiative that will bring many positive results.
 
Despite these achievements, Sambo warned that not enough is being done and gaps in funding are allowing prevalence and mortality numbers to remain high.  For every HIV patient being treated, three more are newly infected, he noted.  Fifty- five percent of HIV infected pregnant women are not receiving ART prophylaxis, while 58 percent of all infected people have no access to ARV treatment.  Life expectancy in the continent has dramatically shortened, with an average life expectancy of at least 60 years in the 1990s, to less than 50 years in 2010. 
 
Sambo also stressed that HIV-TB co-infection continues to be an emerging problem, as the number of TB cases continues to increase and remains the leading cause of death among HIV patients.  The emergence of MDR- and XDR-TB is making the HIV response even more difficult.  Sambo expressed that the failure of integrating HIV and TB services has caused many of the difficulties, and that it’s difficult to achieve integration when two-thirds of funding needs for HIV-TB co-infection are unmet.
 
Health programs, he said, are receiving half of the funding needed for the HIV response.  In total, Africa requires $12 billion to deal with the HIV/AIDS crisis, but is receiving $6 billion.  He said $2 billion is required for the TB response, but $1 billion is available.  In addition, he said $10 billion is needed for health systems strengthening, but African nations have $5 billion at their disposal.
 
But Sambo said funding wasn’t the only issue.  He said African nations need to take on more responsibilities and ownership of programs, and broaden their health policies to go beyond disease control.  In particular, he said, broader health determinants need to be addressed, such as poverty, lack of food security, lack of education, and environmental degradation.

He cited a need for increased support for maternal and child health, as well as a larger focus on women’s and girl’s development.  Nations also need to develop capacity for health research and information systems.  Most importantly, leaders need to make a renewed commitment to fighting the HIV epidemic, as well as use funds more efficiently.

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There were plenty of frightening statistics and unsettling trends highlighted at today’s World TB Day briefing on Capitol Hill. But one photo captured the true scope of the problem in scaling up diagnosis and treatment of the global TB epidemic.

Celine Gounder, MD, an IDSA member and TB/HIV specialist at Johns Hopkins University, described a recent trip to Malawi, where she saw shopkeepers volunteering to collect sputum samples from customers with chronic coughs. The accompanying photo: a man transporting the sputum samples to a laboratory in a small wooden box balanced on the back of his bicycle.

Dr. Celine Gounder discusses the TB epidemic at a Senate briefing

As Dr. Gounder noted, this small community had overcome one of the hurdles in getting suspected TB patients access to proper care. But many others remain. For starters, those specimens so carefully balanced on the bike would be examined using sputum smear microscopy, the only widely available diagnostic test for TB in Malawi. But Malawi has one of the highest HIV prevalence rates in the world, and the vast majority of HIV-related TB cases will be missed by sputum smear microscopy. A more accurate TB test, culture, is not available in the country because of lack of funding. So many of the patients will get false negative results, and continue to transmit the TB bug.

Her presentation provided compelling evidence of the need for more resources devoted to increased laboratory capacity and better diagnostics for TB. But she noted the gap between rhetoric and reality when it comes to TB funding. See Dr. Gounder’s power point here: CGounder_US Senate Briefing_20100324 and below is a video of her presentation.

“Despite the clear need for a heightened response to the global TB problem, funding that has been appropriated for these activities falls short of what was authorized by the Lantos-Hyde Act and what is needed to make decisive progress,” she said. “USAID, which is the primary US agency conducting global TB activities, received only $225 million in FY 2010 of the $650 million dollars authorized.”

She noted in particular that the White House’s Global Health Initiative includes TB treatment targets that are much lower than those set out in the Lantos-Hyde Act, which reauthorized PEPFAR. And she said HIV/TB co-infection was getting particularly short-shrift.

“Little more than lip service has been paid to delivery of TB-related interventions by HIV programs,” Gounder said.  “Only 16% of all TB patients were tested for HIV in 2007. Only 2.2% of HIV patients were screened for TB. And only 30,000 of HIV patients, 2% of the target, received isoniazid preventive therapy, which has been proven to reduce the risk of TB and mortality by one-third to two-thirds.”

Gounder’s remarks came at a Senate briefing on the global TB epidemic, which included a special focus on drug-resistant TB. The event, entitled “Bringing Methods to Scale: New Perspectives in the Changing World of TB,” also featured a presentation by Ernesto Jaramillo, team leader for MDR-TB for the World Health Organization’s Stop TB Department, who detailed the WHO’s newest data on drug-resistant TB. (more…)

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What is more worrisome when it comes to drug-resistant TB: What we do know about the epidemic? Or what we don’t know?

The latest World Health Organization report on the epidemic provides plenty of both—some grim facts and some disconcerting question marks.  Take these nuggets:

*A shocking 41 percent of countries cannot provide reliable data on the scope of drug-resistant TB within their borders, according to the report, on the eve of World TB Day.

*The up-to-date tools needed to diagnose drug-resistant TB are not available in more than half of the 27 countries most heavily affected by multidrug-resistant TB (MDR-TB).

*An estimated 440,000 new cases of MDR-TB emerge each year, but only 7 percent of those cases are actually being detected. And even fewer are being treated. One-third of the estimated new cases each prove fatal. As for extensively drug-resistant TB (XDR-TB), there’s even less information.

In many of the places that do report good data, the WHO found MDR-TB at record levels; in one region of northwestern Russia, for example, 28 percent (more than 1 in four) new TB cases involved a strain of the bug that could not be treated with standard TB medicines. Other places could be even worse. But poor surveillance, inadequate laboratories, and antiquated diagnostics obscure the full scope of the threat.

 Dr. Mario Raviglione, Director of the WHO Stop TB Department, and Dr. Marcos Espinal, Executive Secretary of the Stop TB Partnership, ran through some of this data in a briefing for TB advocates and experts in Washington today. They also highlighted the lack of adequate funding or political commitment to TB, saying this urgent global health threat simple was not getting the attention it requires.

Dr. Raviglione said Europe is “de facto” asleep when it comes to TB, no UN leader “has ever recognized TB as a priority,” and no rich countries have ever launched a presidential-level initiative to combat the disease. They two WHO officials commended U.S. leadership on TB but said much more needs to be done here and around the world.

Click here to see the full WHO report.

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Kevin M. De Cock, MD, has been tapped to lead a new center focused on global health at the U.S. Centers for Disease Control and Prevention. A longtime leader in international health, Dr. De Cock has been at the forefront of the battle against the HIV/AIDS epidemic for more than a decade. As director of the World Health Organization’s Department of HIV/AIDS from 2006-2009, he oversaw all of WHO’s work assisting low- and middle-income countries to scale up treatment, prevention, and support programs. He is now finishing up a stint as Director of CDC’s Kenya office before he moves to Atlanta to launch the CDC’s new Center for Global Health. In this Q&A, he talks about the vision for this new center and the challenges ahead.

 Q: You are about to take the helm of a new center within CDC that will amplify the agency’s work on global health. Why did CDC leaders feel this new center was needed and what are the objectives?

A: When the CDC’s director, Dr. Tom Frieden, took up his functions in the middle of last year, he did two things. Firstly, he defined global health as one of CDC’s core priorities. And I think the significance, the symbolism, of that is considerable. Although CDC has done international work since its inception, it’s really the first time a CDC director has so explicitly named global health as one of his priorities. And to match that rhetoric, he also decided CDC’s work in global health should be consolidated and therefore created a new center.

The creation of the new center does mean that CDC has to think more ambitiously and more strategically about its role in the world, in the hugely changed international diplomatic environment that is so different from just ten years ago. We will be thinking about science and public health priorities and how best to do our work in the 40 or 50 countries where we are engaged. We will work to get a better impact, a more measurable impact, and one that can be communicated more clearly. 

Kevin DeCock who lead a new Center for Global Health at the CDC

Q: You have a long history of working on the global HIV response both in Kenya with CDC and with the WHO.  Many of us are concerned that the Administration’s Global Health Initiative, with its welcome expanded reach, will in fact come at the expense of the robust response envisioned for HIV and TB through the Lantos-Hyde Act.  Already we see evidence of this in less than ambitious treatment targets for HIV and TB.  What is your own assessment of this? Are you concerned about a loss in momentum toward HIV treatment targets that you helped craft, such as Universal Access by 2010? 

A: I think that’s a very relevant question. I have no doubts about the commitment of the Administration to building up the impact of PEPFAR I. And as far as PEPFAR II is concerned, the funding remains huge and the targets remain ambitious and the work is very extensive.

Now at the same time, there’s no doubt that we have to look to the longer term future and begin to think more deeply about how does the long-term global response get funded? It’s unrealistic for one country to fund the whole response to the pandemic, which is likely to stretch into decades to come.

Actually, it’s a coincidence that you asked this, because we’ve been discussing these sorts of questions for Kenya yesterday and today. And I think we’re okay for the time being. But obviously with 33 million people infected with HIV, and with around 4 or 4.5 million on therapy right now and others waiting to become treatment eligible, the costs of HIV/AIDS are going to increase and we do need to think about innovative methods of financing—sharing the burden more broadly; getting other donors involved, such as emerging economies; getting affected countries themselves to take up some of the costs, which some of them could; and making the response more efficient and effective. I’m not so worried about the immediate short term, but I certainly think some deep thinking is required about the longer term.

Q: Similarly, the tuberculosis treatment targets detailed in the Administration’s GHI consultation document was considerably lower—roughly half—of the goals laid out in Lantos-Hyde. Do you have concerns about a pullback on fighting TB, particularly with the rising threat of multidrug-resistant TB (MDR) and extensively drug-resistant TB (XDR-TB)?

A: I think tuberculosis is always at risk of getting forgotten. The history of TB funding has always been cyclical. It rises when TB seems to get out of control, then the response is funded, the cases come down, and then people’s attention gets drawn elsewhere. That’s been a phenomenon, including in the US, over many years. So I do think there’s a need to continually remind people about tuberculosis. And although I think we’ve done reasonably well addressing TB within the context of the AIDS epidemic, there’s still enormous work to do.

As far as MDR and XDR, these are very important issues. We need better surveillance data, but XDR has been most severe in a limited number of places and MDR also is not a huge problem everywhere. The real answer to drug-resistant TB is prevention and better functioning programs, since it is poorly functioning programs that are at the root of MDR and XDR TB.  I think the response under the GHI is fairly robust, but tuberculosis does need continuous advocacy to ensure it’s kept on the front burner and policymakers continue to pay attention to it.

Q: What role will the CDC play in the Global Health Initiative?  We noted last week the appointment of Amie Batson as the point person for the GHI at USAID, but certainly our physician members see CDC as a critical player in global health.  Will there be a similar liaison from the CDC? And if not, how will the agency ensure that its voice is heard in this new approach to global health?

A: The discussions are ongoing about the governance of the GHI–those discussions are unfinished. But let me reassure you that the director of CDC, Dr. Frieden, is paying the utmost attention to this issue and has been intimately involved … And as this new center is stood up, he’s been paying extraordinary  attention himself to global health issues and these Washington discussions. The CDC will be represented at the highest levels.

Q: Some advocates have argued that CDC has suffered as an agency because it is far from Washington’s reach in Atlanta.  What plans do you have to engage with the Washington community of policy makers, program implementers and advocates on global health?

A: That question has some validity, but there are some advantages also to being in Atlanta. One of the original reasons CDC was put in Atlanta was to deal with malaria in the southern United States in the early 1940s. Two advantages of not being in Washington are 1) it has allowed the agency to develop a very strong technical focus and identity, because being away from the political spotlight, I think an emphasis has been put on its technical work and 2) it’s allowed the agency to grow and occupy more physical space, which in D.C. frankly might have been quite difficult.

On the other hand, meetings in Washington get called, sometimes on short notice, and there isn’t always someone to fly up from Atlanta and so we miss out on discussions. We do have an office in Washington, with a Washington-based director. There’s a deputy for the agency for policy in Washington, who has just been appointed. And for global health, we also have a deputy director for policy and communications position that will be Washington based. We are recruiting as we speak.

Q: There was new evidence presented at CROI last month about the benefits of HIV treatment as prevention. How do we educate policymakers about the broader community benefits of HIV treatment, including the reduced transmission of HIV and TB?

A: Policymakers pay attention to data if they are explained to them in the right way, and we are beginning to see pretty persuasive data on HIV treatment as prevention, especially with discordant couples, where one person is infected and HIV treatment prevents the second person in the couple from becoming infected. To my mind, there’s only one direction this debate is  going—it’s towards early treatment and more widespread treatment. It is giving a biological and biomedical justification for the aphorism that treatment and prevention are inseparable. It’s a very important and emerging theme in HIV/AIDS work.

The role of HIV treatment as prevention, the impact at the community level of widespread treatment on HIV transmission, and the question of when to start treatment for the individual, and the impact that would have on individual health and on TB at the community level–these allied questions are, to my mind, the most important research priorities in HIV medicine today.

Q: On drug-resistant TB, there’s a lot of excitement about new diagnostics in the pipeline that could lead to faster, better tests for drug-resistant strains of TB. If such a vital tool comes to market soon, will the US have the resources to help get it out widely to the field?

A: If new tools become available, such as diagnostics, that are shown through research to improve outcomes or to make interventions more effective, more efficient, then they do get adopted and sometimes remarkably quickly. We’ve certainly see that within HIV medicine. You have to be impressed with the scale of up therapy and rapid HIV testing. There is also a movement in programs in lower and middle-income settings towards laboratory strengthening and an interest and emphasis on point-of-care tests, be they for malaria , TB or HIV. But the technology has to be developed first, has to be refined, and has to be evaluated.

Q: You haven’t officially transitioned into your new job yet and are wrapping up things in Kenya as we speak. What kinds of successes has the CDC seen in Kenya and what challenges remain for your successor there?

A: CDC has had a very interesting history in Kenya. It was in 1979 that the first D.C. assignee arrived here and he was sent to initiate collaborative malaria research.  And up to and until the early 2000s, the agenda was almost exclusively research, which CDC always tries to link to policy development and programs.

But with the advent of PEPFAR, and subsequently our work in emerging infectious and global disease detection, we’ve become much broader. Our research has had direct impact on health policy. For example, malaria research on the efficacy of insecticide-treated bed nets was extremely important. In HIV, the clinical trial of HIV treatment to prevent mother-to-child transmission through breastfeeding contributed to a change in international guidelines.

As for what comes next, we have been very infectious-disease oriented. It is time that we begin to extend our work—and this is mandated actually through the GHI—to non-communicable disease priorities, including tobacco use, salt intake, hypertension, diabetes and injuries. And we have to address maternal and child health and extend our work to neglected tropical diseases. These will be the challenges moving forward.

Q: When you get to Atlanta, what will the new center’s structure look like and what will its portfolio include?

A: It will be structured like other centers within the CDC, with an office of the director that has central functions like policy and communications. Currently there are 4 operational divisions in the new center. The first one is the division of global HIV/AIDS, the operational arm of the CDC for PEPFAR implementation. A second division is focused on parasitic diseases and malaria. Third, there’s a division called global disease detection and emergency response, which does international work on emerging infectious diseases, response to outbreaks, international surveillance and response to humanitarian emergencies. And fourth, a division that deals with health system strengthening and is well known for its work in field epidemiology training. We will have to work towards better integration of all CDC’s work in global health.

There is of course a great deal of work in other aspects of public health with global implications done in other parts of the agency, for example our work on immunizations. Whether those will move into the new center is under discussion, but the important point is that the new center will  do all it can to support all of CDC’s international work.  And perhaps that summarizes the identity we seek – a global public good for public health.

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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

It’s been almost 3 years since the World Health Organization developed its recommendations and goals for male circumcision. As Kim Dickson, MD, an AIDS expert with the WHO, outlined in a presentation at CROI today, scale-up has not been speedy or simple.

In her talk, Dickson noted that the WHO identified 13 priority countries for scale up, especially those with high prevalence, generalized heterosexual epidemics, and low levels of circumcision.  All of the countries are in eastern and southern Africa. The goal: reach 80 percent of adult males and newborns by 2015 in the target countries. 

This intervention could prevent more than 4 million adult HIV infections over 15 years, but millions of circumcisions would have to be performed during this time period. The approximate cost of the procedure in these settings is $50. 

 Advocacy has been vibrant at all levels, and there have been multi-stakeholder consultations in all countries including various groups. A number of funding agencies have made money available for male circumcision-related activities, including PEPFAR, the Global Fund, and the Bill & Melinda Gates Foundation.  Male circumcision policies have been developed in Lesotho, Namibia, South Africa, Swaziland, Uganda and Zimbabwe. Kenya has developed actual guidelines.  Most countries are focused on so-called “catch-up” strategies to reach adult men, but longer term neonatal strategies are under consideration in Botswana, Swaziland and Zambia.  Provider training programs have been implemented in almost all 13 countries.

The bottom line question, however, is how many circumcisions have been done?  (more…)

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