WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Fifty-sixth session Noumea, New Caledonia 19-23 September 2005 Provisional agenda item 17
WPR/RC56/13 21 July 2005 ORIGINAL: ENGLISH
FOLLOW-UP REPORT ON TUBERCULOSIS, HIV /AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS Significant progress has been made in achieving the tuberculosis (TB) control goals set by the Regional Committee for the Western Pacific at its fifty-first session in 2000 1 , and in meeting the various goals that have been set for HIV/AIDS prevention, care and treatment. More specifically, in the area of TB control the Region already has exceeded the target of an 85% treatment success rate. It also is very close to achieving the 2005 targets of 100% coverage for directly observed treatment, short course (DOTS), and a 70% TB case detection rate. For HIV/AIDS, the "3 by 5 Initiative" has been a catalyst for action in the Region. Partnerships developed under the initiative have contributed to a significant increase in the number of people with HIV who now receive treatment in developing countries. The TB-HIV co-infection also presents a challenge to the Region. There is growing concern in some countries and areas in the Region over the limited progress in terms of initiating or scaling up TB-HIV collaborative activities, including TB-HIV surveillance. The Regional Office, in collaboration with Member States, is developing the Regional Strategic Plan for 2006–2010 that will contain strategies to overcome the challenges in achieving the regional goals of reducing TB prevalence and mortality by one half by 2010. The HIV programme is also looking towards a new goal of universal access to care and treatment. This would mean continuing to work in countries and areas with priority needs, while at the same time providing access to care in countries and areas with low HIV prevalence. This paper is presented for information of the Regional Committee and for discussion at its fifty-sixth session.
1
Resolution WPR/RC51.R4.
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1. CURRENT SITUATION
1.1
Achieving the regional goals for TB control by 2010 The Stop TB Special Project, which was established in 1999 by the Regional Director,2 set
regional goals of reducing the TB prevalence and deaths by one half by 2010. The Region has made significant progress towards achieving initial targets on the road to reaching the eventual goals. The regional treatment success rate already exceeds the 85% target. At the end of 2003, DOTS coverage was close to its target of 100%. Although still short of the 70% case detection target, the regional case detection rate increased from 40% in 2002 to 52% in 2003. With the progress already achieved in most countries with a high burden of TB, it is expected that the Region will be very close to achieving the initial target of a 70% case detection rate by the end of 2005. Despite the progress, potential threats and challenges exist. As DOTS rapidly expands, efforts must be made to improve and sustain the quality of DOTS. In addition, multidrug resistant-TB (MDRTB) and TB-HIV are potential threats that may undermine the gains made towards achieving the TB control goals. To address these challenges and propel the Region towards the 2010 goals, the Regional Strategic Plan to Stop TB for 2006-2010 is being developed and will be presented to the Regional Committee at its fifty-seventh session in 2006. 1.2 Progress in HIV/AIDS prevention, treatment and care The target set by the "3 by 5 Initiative" of providing antiretroviral treatment to 3 million people living with HIV/AIDS in developing countries by the end of 2005 is a useful interim measure. But the long-term goal of WHO and countries and areas should be universal access for prevention and care and treatment for all, in particular the most vulnerable. The environment for HIV/AIDS prevention and care, including antiretroviral (ARV) therapy, has improved very significantly in recent years. More resources have been allocated to HIV/AIDS interventions, better policies are in place, senior political figures have become involved in HIV/AIDS events, and national strategic plans have been amended in line with these developments. Key progress has been made in implementing the 100% condom use programme. The programme has expanded in Cambodia, China, the Lao People's Democratic Republic, Mongolia, the Philippines and Viet Nam. There have been clear policy shifts in China, Malaysia and Viet Nam last year towards the
2
Resolution WPR/RC50.R5.
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adoption of strong prevention approaches, such as the expansion of the needle and syringe programmes in Viet Nam and methadone maintenance treatment in China. 1.3 Addressing TB -HIV: Two diseases, one patient HIV and TB are the leading killers among the infectious diseases today and together they form a deadly relationship. Among people with HIV/AIDS, TB is the leading cause of death. In the Region, TB-HIV has not reached epidemic proportions but is already serious in some areas. In Phnom Penh, Cambodia, the percentage of TB patients who are HIV-positive has risen rapidly in the last several years to reach 31% in 2002. WHO is helping countries and areas coordinate their national TB and AIDS programmes. A regional framework for TB-HIV has been drawn up and now serves as the basis for several national frameworks. Cambodia has made good progress and developed a framework for implementing TB-HIV collaborative activities and the continuum of care for people living with HIV/AIDS and TB. In China, a national framework for TB-HIV is being finalized. A conference on TB-HIV was held for the Mekong countries through the collaboration of WHO, other partners and the Ministry of Health Viet Nam in October 2004 to allow countries and areas to share experiences in setting up collaborative TB-HIV activities. A biregional managers workshop is planned for the beginning of 2006.
2. ISSUES
2.1
Tuberculosis
2.1.1 The need for improving the quality of DOTS implementation With DOTS rapidly expanding, the quality of its implementation is an important concern. This includes areas of laboratory diagnosis, training and supervision, drug supply management, and the reporting and referral of cases. Poor quality DOTS implementation undermines the gains from DOTS expansion and hinders case detection and effective case management. Human resource capacity and laboratory quality also need to be addressed.
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2.1.2 The need for addressing the potential threat of MDR-TB MDR-TB is an ever-present danger. TB patients are more likely to develop drug resistance in areas where there is poor implementation of the TB control programme. Multidrug resistance is a serious threat because it is more difficult and more expensive to treat than non-resistant TB. The Philippines has a DOTS-plus project in place, and Mongolia is receiving support from the Global Fund to Fight AIDS, Tuberculosis and Malaria for a similar project. 2.1.3 Need for engaging all health providers for TB control The public -private mix DOTS (PPM-DOTS) is an approach that engages all health providers in TB control and has shown promising results in China and in the Philippines. However, its introduction and scale up has been very limited in the Region. This is mainly due to the lack of technical capacity on PPM-DOTS and insufficient efforts to advocate PPM-DOTS at all levels. Improving collaboration between the TB programme and other service providers increases access to quality TB services for all TB patients and increases case detection. 2.1.4 The need to sustain commitment and adequate financing Some countries and areas in the Region have yet to achieve their targets of 2005, which is an important intermediate step towards achieving the regional goals. Many countries and areas also face potential threats, such as MDR-TB and TB-HIV coinfection, that will undermine the gains in TB control. The implementation of the Regional Strategic Plan for 2006-2010 will address this, but it will require a further commitment to sustain investments in TB control. The Global Fund to Fight AIDS, Tuberculosis and Malaria is an important funding source over the next few years, but the continued inflow of funds largely depends on performance of programmes and sustained commitment from countries. 2.2 HIV/AIDS
2.2.1 The need to address the high HIV/AIDS burden in some countries and areas, and the threat of a generalized epidemic in some areas of other countries In the Western Pacific Region, more than 1.5 million people were estimated to be living with HIV/AIDS at the end of 2004, and an estimated 120 000 people in the Region are expected to die of AIDS in 2005. Cambodia and Papua New Guinea are facing generalized epidemics. China, Malaysia and Viet Nam are concerns because of the danger of HIV bridging into the general population from infected populations with high-risk behaviour. All other countries have low estimated HIV
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prevalence rates. But high rates of prevalence for sexually transmitted infections (STI) in some of these countries and areas indicate the presence of high-risk sexual behaviour that is a significant threat. 2.2.2 The need to overcome challenges to effective HIV/AIDS prevention, care and treatment As additional resources are allocated to care and treatment, it is important to continue to give adequate attention and resources to prevention. Also, significant challenges exist to effective programme implementation, such as stigma and discrimination, weaknesses in health systems, and human resource capacity constraints. 2.2.3 The need to scale up the coverage of condom use programmes and other targeted prevention programmes The implementation of prevention strategies, such as the 100% condom use among sex workers and their clients and harm reduction programmes among injecting drug users, has been so far limited to pilots in several countries. Coverage is not wide enough to achieve an impact. 2.2.4 The need to enhance HIV surveillance systems Accurate information is essential to respond effectively to the epidemic and to monitor resistance to STI drugs and antiretroviral drugs. Surveillance systems in a number of countries and areas are still unable to monitor the HIV/AIDS epidemic adequately, and comprehensive, secondgeneration surveillance systems are still not systematically or fully implemented in all countries and areas. The use of effective surveillance data is still limited. 2.3 TB-HIV
2.3.1 The need to engage the threat of TB-HIV HIV-related TB poses a threat to the gains achieved thus far in TB control in the Region. HIV helps fuel the TB epidemic. TB is the most common opportunistic infection in people infected with HIV, and it is the leading cause of death among people with AIDS. TB-HIV coinfection is a serious problem in several areas in Cambodia, Papua New Guinea and Viet Nam, and a growing concern in some population groups in China and Malaysia. Establishin g collaboration between HIV and TB programmes is an essential first step in addressing TB-HIV in countries and areas.
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2.3.1 The need to establish TB-HIV surveillance Surveillance of HIV among TB patients is increasingly important, as the HIV epidemic has continued to fuel the TB problem. Surveillance of TB-HIV is a starting point for intensified case detection and for the implementation of TB-HIV interventions. However, TB-HIV collaborative activities based on the regional TB-HIV framework, particularly surveillance aspect, have yet to be introduced in most countries in the Region. Cambodia has developed strong links between the two programmes that led to shared activities in the treatment of the two diseases.
3. ACTIONS PROPOSED
The following actions by Member States are proposed for consideration by the Regional Committee: For TB (1) Sustain political commitment with long-term planning, the provision of adequate human resources and sustainable financing to reach the regional goals of 2010. (2) Develop and implement the national plans based on the Regional Strategic Plan for 2006-2010, which is being finalized by the Regional Office in consultation with Member States. The elements of the Regional Strategic Plan will include implementing measures to improve the quality of DOTS, increasing access to quality TB services for all TB patients, implementing collaborative TB-HIV activities, and implementing activities to address MDR-TB. (3) Implement measures in countries and areas that have not achieved the regional TB control targets to ensure that: (a) 100% of the population have access to DOTS, (b) 70% of the estimated cases are detected, and (c) 85% of the identified cases are successfully treated. For HIV/AIDS (1) (2) Promote advocacy to develop political support for an adequate response to HIV/AIDS. Reduce stigma and discrimination by reinforcing a favourable environment, and develop greater involvement of communities and people living with HIV/AIDS in the design, implementation and evaluation of care and prevention programmes.
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(3)
Improve coordination of efforts to prevent and control HIV/AIDS at country level through the effective implementation of the “three ones" principles.
(4)
Strengthen surveillance activities, including data analysis and the dissemination of high-quality epidemiological and behavioural data, in order to monitor the HIV/AIDS epidemic and to plan effective interventions, in particular in the domains of HIV/AIDS and TB jointly.
(5)
Scale up well-targeted interventions, such as needle and syringe exchange programmes and drug treatment for the prevention of HIV in injecting drug users, and the 100% condom use programme for the primary prevention of STI, including HIV/AIDS.
(6)
Strengthen STI services in both public and private sectors, particularly for areas or populations with high STI prevalence.
(7)
Promote the universal access to HIV/AIDS care and treatment as to ensure equitable access for the most vulnerable populations.
For TB -HIV (1) Advocacy at the country level with the two programmes—National AIDS programme and National TB programme. (2) Ensure effective collaboration between TB and HIV programmes. Depending on the country and area situation, countries and areas are urged to establish a national TB-HIV framework, including TB-HIV surveillance.