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World TB Day 2009 Media Call Transcript

ACTION, 24 March 2009

Operator:  Good day and welcome to the World TB Day media call.  This call is being recorded.   At this time, I would like to turn the call over to Joanne Carter; please go ahead.   Joanne Carter:  Thanks very much, operator and thanks to everyone for taking the time to join us today on this important call on World TB Day and thanks for your patience.  We’re starting a few minutes late. Today’s call is jointly sponsored by the ACTION Project, which is a global TB advocacy project and by the Infectious Diseases Center for Global Health Policy and Advocacy.   My name is Joanne Carter and I’m the executive director of RESULTS Educational Fund in Washington, D.C. and we’re the secretariat for the ACTION project and I’ll be moderating this call.   On today’s call, several experts and activists will be discussing two important reports that were just released today.  First, the World Health Organization’s annual TB control report which has important new data showing that the number of people co-infected with HIV/AIDS and TB is essentially double last year’s estimate.  And a report issued by the ACTION project called “Living with HIV, Dying of TB,” which shows that major HIV/AIDS donors are doing far too little to address the shocking gap of TB-HIV integrated services.   Just to give you a sense of how severe that gap is, the WHO also estimates that only 2 percent of all people living with HIV are being screened for TB.  This is also double last year’s estimate.  But rather than being good news and an indicator of how far we’ve come, I’d argue that this is a measure of how far we still have to go to tackle this co-epidemic.   One logistical note before we begin, due to a previous speaking engagement at the Stop TB Partners Forum in Brazil, our first speaker, Dr. Dick Chiassen will need to leave our call earlier, so he won’t be able to stay through the whole call.  So just to accommodate any questions the media may have for him, we’re going to have Dick speak first, take a few brief questions, then go back to the rest of our speakers and additional questions.   So just to start, Dick Chiassen is the director of Johns Hopkins Center for Tuberculosis Research.  And he’s also director of the Consortium to Respond Effectively to the AIDS/TB Epidemic (CREATE).  And he’s also a member of the International Disease Society of America’s Global Infectious Disease Scientific Advisory Committee.   So Dick, thanks for joining us from Rio.  And please, go ahead to give us just some opening perspective especially on the WHO’s report released today.   Dick Chiassen:  So good afternoon everybody and thank you.  I’m speaking to you on a cell phone on a table top in a room that now does have power.  And the conference here in Brazil, the Stop TB Partnership meeting is hopelessly behind schedule, so I’m not as crushed for time as originally thought.  But I do want to take a few moments to talk about the new report from the World Health Organization on the burden of HIV-related TB.   It’s been clear for a number of years now that the impact of the HIV epidemic on tuberculosis has been staggering.  And if you look at the burden of TB in Africa in particular there has been more than a tripling of TB rates in Africa over the last 15 or so years as the HIV epidemic has grown there.  HIV is the most important risk factor for tuberculosis in the world.  It increases the risk of TB dramatically in people who are co-infected.  Those of us who have been working on the ground in Africa have seen this extraordinary burden clinically but the surveillance mechanisms that the World Health Organization relies on have not adequately captured just how important HIV related TB is in Africa until the last year. Due to some improvements in surveillance methodologies in Africa, we have new data showing that the prevalence of HIV related TB is essentially twice as high as previously thought by the mechanisms used by the WHO to estimate the TB burden.  And importantly, the number of deaths related to tuberculosis and HIV are double what they were previously thought to be.   So due to this improved surveillance we now have very good and certainly much better than before data showing the incredible impact of the HIV epidemic on tuberculosis and particularly the impact on tuberculosis-related deaths in the world.  And in this new report showing the increased burden of HIV related TB showing that while HIV is associated with about 15 percent of the global burden of tuberculosis much higher than that in Africa, but globally it accounts for 15 percent of tuberculosis in the world.  It accounts for a quarter of the deaths from tuberculosis.  And tuberculosis is the most common cause of death in people with HIV.  If we look at the African continent, AIDS is the leading cause of death in Africa for all causes and people dying in Africa with AIDS are dying of tuberculosis.   So all of this underscores the importance of HIV-related TB and the importance of trying to combat it.  And I’ll just briefly say that there are three strategies that need to be pursued to control HIV-related TB and they involve finding the TB that is there, treating it, once it’s found and then preventing TB in people who don’t have it.   In terms of finding TB, the diagnostic tests that are available in most of Africa are hopelessly antiquated and incredibly insensitive.  And so finding new technology to more quickly and reliably diagnose TB is a very important strategy.  There’s a very high prevalence of undiagnosed tuberculosis in people with HIV in Africa.   In terms of treating tuberculosis we have good treatment for tuberculosis currently but it’s more than 50 years old and we need to have better treatment.  Treatment that will cure tuberculosis more quickly, that will cure multidrug-resistant tuberculosis which is increasingly common including in people with HIV in Africa and that will be faced to administer with antiretroviral drugs.  We have the paradox now of people surviving their HIV because of antiretroviral drugs, then dying of tuberculosis because of inadequate treatment.   And then finally, with prevention of tuberculosis we have very good effective inexpensive preventive therapy for tuberculosis but it’s not being used.  The World Health Organization report estimates that fewer than 2 percent of HIV infected patients around the world who should be getting TB preventive therapy are actually receiving it.  It’s really disgraceful.   And then controlling the spread of tuberculosis in HIV clinics, controlling the spread of tuberculosis in hospitals and in the community is another important strategy.  And all of that leads us to the need to invest more in tuberculosis control.  Currently major global donors who are supporting HIV efforts such as PEPFAR and the Global Fund are not supporting HIV-related TB interventions to the extent that is required.  And I’ll end with that.   Joanne Carter:  Thanks very much, Dick.  Just to get a sense of your time, should we go ahead and take some questions from journalists now because you will need to step out? Dick Chiassen:  Well, that would be fine by me.  That would be great.   Joanne Carter:  OK.  Why don’t we go ahead, then, operator.  Can you just tell folks how they can go ahead and ask some questions? Operator:  Of course, thank you.  Today’s question-and-answer session will be conducted electronically.  If you would like to ask a question, you may do so by pressing the star key followed by the digit 1 on your touch-tone phone.  We will proceed in the order that you signal and take as many questions as time permits.  If you’re joining us on a speakerphone, please make sure your mute function is off to allow your signal to reach our equipment.  Again, that is star 1 if you have a question.   And we will take our first question from David Brown with the Washington Post.   David Brown:  Yes, hi.  Thanks.  Dr. Chiassen, can you say how – what the life expectancy is for an HIV patient with a given stage of disease, given CD-4 count, let’s say, with and without tuberculosis so we have some sense of how life – how longevity is shortened by co-infection with TB? Dick Chiassen:  Well, the – I guess the key issue is when the tuberculosis develops.  People with HIV are increasingly susceptible to TB the more immuno-compromised they become as their CD-4 counts fall.  But we know that the risk of tuberculosis essentially doubles the second someone is infected with HIV.  So HIV immediately confers an increased risk of TB and then it keeps growing as their CD-4 count falls.   Once tuberculosis occurs, once someone becomes sick with TB, which can occur at any time during the course of HIV infection, then without treatment the likelihood of death is essentially 100 percent within 6 months.  With treatment, we can cure TB as long as it’s not drug-resistant TB.  The problem in Africa is that far too many people who have TB aren’t being diagnosed and they’re not being treated and so they die and they die quickly.  So I can’t answer your question with a round number for any given CD-4 count.  What I can tell you is that the risk of TB is high with HIV and it gets higher and higher the more immuno-compromised the patient becomes.  And once it occurs it’s uniformly fatal without treatments in very few months.   David Brown:  OK.  Thanks.   Operator:  And as a reminder, it is star 1 if you would like to ask a question.  And at this time, there are no other questions.   Joanne Carter:  Thanks very much, operator.  And I would say Dr. Chiassen, if you can stick around, that would be great.  I understand if you need to leave.  Let’s then move on to our next speaker.  And next we’re going to hear from Paul Jensen who is the Global Research Coordinator for RESULTS Education Fund and the TB Action Project who will give us a summary of the findings of the report that Action released today Living with HIV, Dying of TB, A Critique of the Response of Global AIDS Donors to the Co-Epidemic.  And Paul oversaw the development of this report.  So Paul, please go ahead.   Paul Jensen:  Thanks, Joanne.  So I’ll start by briefly describing the context in which we conducted the research and then I’ll describe what we analyzed and what we found.   So first, the context, starting in the last 1980s research began showing that TB and HIV interacted in a deadly way at the level of the patients.  And then throughout the 1990s it became evident that at the population level, HIV was driving a resurgence of the TB epidemic especially in sub-Saharan Africa.   In 2002, WHO issued recommendations calling for an integrated response to TB and HIV.  These were revised in 2004.  And since then they’ve provided clear guidance on how to integrate the response to TB and HIV.  And they made it clear that an HIV program that does not include TB interventions where the disease burden demands it is not properly conceived.   And that meanwhile, over the years, the number of high profile people like Nelson Mandela and Archbishop Desmond Tutu have made public pronouncements that at times at HIV/AIDS international conferences urging that TB be addressed in people living with HIV.   And then, lastly, the WHO has provided TB-HIV costs estimates or funding that’s needed annually to reduce TB deaths among people with HIV by 80 perecnt by 2015.  And that figure totals $19 billion over the next 7 years which includes ARVs.  But when you look at just what’s required for TB-HIV intervention specifically $615 million was needed in 2009.  But it’s important to keep in mind that these calculations were done before these new surveillance data came out so they’re likely to undershoot the actual costs by a considerable measure, but these are the cost estimates that we have to go on. So all of this is to say that the newest data coming out today while they’re alarming, they shouldn’t cause any epiphanies among those administering AIDS programs.  And with that as a context, and doing this research we asked a pretty simple question, to what extent has the world’s largest supporters of global AIDS efforts addressed TB, given TB is the disease most likely to kill people being served by these programs.  And how is this reflected in policy and funding and programming?  And in the sets of activities or outputs that they monitor and evaluate in order to measure their effectiveness on the ground? And we focus on four institutions, the President’s Emergency Plan for AIDS Relief in the U.S.; the World Bank’s Africa Multi Country AIDS Program; the Global Fund to Fight AIDS, TB and Malaria; and the Support for HIV that’s provided by the U.K. government’s Department for International Development.  And we chose these donors because they provide substantial resources that in many ways that are key to driving the global AIDS agenda.  Then lastly all of them are formally, rather, declared a commitment to integrate their HIV/AIDS programming with that for TB.   So with that I’ll take you through some of the key findings that are fleshed out in more detail within the report, but in broad strokes, we found the following.  Resources are insufficient.  It’s actually impossible to even say what the four institutions collectively are providing because some don’t even disaggregate their funding data for TB-HIV.  But where we could measure resource levels, however, we found that they were modest.   In terms of policies, they vary considerably from clear and ambitious to incoherent or sometimes non-existent.  Within individual AIDS programs or projects TB-HIV activities when they do occur are typically small in scale and narrow in scope.  And monitoring and evaluation of activities when it does occur is sporadic and often voluntary and does has not allowed any of the institutions to tally program by program or country by country what it’s doing for TB-HIV and to what outcome in any sort of comprehensive way.   So now I’ll briefly go through the institutions individually and I’ll touch on key findings.  First, PEPFAR, the U.S. global AIDS initiative.  It provided $18 billion for HIV/AIDS over the last 5 years concentrated mostly in 15 focus countries, 12 of which are in sub-Saharan Africa.  And PEPFAR has pretty clear and ambitious TB-HIV policies.  In fact, TB-HIV is categorized as a quote “priority program area” and individual country teams are urged to scale up TB-HIV activities.   What we found though is that funding and programming are both insufficient when you consider the disease burden.  Any initiatives and its own stated goal which aims to ensure that all people with HIV are screened for TB.  And that all TB patients are provided HIV counseling and testing.  And PEPFAR itself describes the scale-up of TB-HIV activities as slow.  They also identified broad gaps.   And we analyzed PEPFAR’s country operational plans they are broad planning documents for 12 of the focus countries that are in sub-Saharan Africa.  And just to clarify these are broad planning documents and they don’t get into the nitty gritty of every activity but they’re the most detailed accounts of programming that PEPFAR makes available publicly.  And in the absence of more concrete data they provided a pretty decent proxy for what they’re doing on the ground.   And the plans list out projects in their project components.  And so we just went through and we counted how many project components included at least one TB-HIV activity.  And because they’re broad documents we didn’t try to analyze the scope or type of the individual projects, just if they included at least one TB-HIV activity.  And we found that over the past 5 years the number and percent of these project components increased from 4 percent in 2004 to 23 percent in 2008.  And this suggests progress but modest progress with less than a quarter of project components planning to address TB-HIV in any way.   And next, the World Bank’s Africa Multi Country AIDS program or the Africa MAP.  And this was launched in 2000 and has committed since then over $1.6 billion to support HIV/AIDS programs in Africa.  TB-HIV efforts within that program are largely incoherent and poorly tracked.  There’s no TB-HIV policy strategy or monitoring and evaluation framework in place to guide TB-HIV activities.   In 2007, the Bank issued a new agenda for action for HIV/AIDS in the Africa region which we were consulted on while it was being developed.  And it includes a statement of commitment to integrate HIV/AIDS and TB efforts.  But the MAP doesn’t actually have a strategy for doing this.  And while MAP resources can be used for TB-HIV it’s impossible to tell from the public documents how much funding, if any, is provided on a project by project basis because the budget information doesn’t disaggregate funding of TB – for TB-HIV, rather.   The MAP also does not require its projects to monitor and evaluate TB-HIV activities or even activities to address opportunistic infections generally.  And for this reason, it’s impossible to tell the extent the effectiveness of TB-HIV activities that it’s contributing towards.  And this isn’t to say that they’re not doing anything.  We analyzed the project documents for MAP in seven countries with high burdens of TB and HIV/AIDS.   And in the early phases of these projects going back to 2000 we found that only three of the seven, Ethiopia, Burundi and Rwanda included any planned TB-HIV activities.  And five of those have since moved on in to their second phase and of those five, only two of them -- Ethiopia and Kenya -- include any plans for TB-HIV activities.  So again it’s impossible to determine the level of resources being provided in these cases.  And none of the projects address TB-HIV in a more comprehensive way in their second phase, than they did in their first phase.  And this is in spite of the fact that new international guidance provided by WHO and the bank’s new agenda for action were issued in the meantime.   And they are also two internal evaluations of the MAP project and the reports include almost no references to TB-HIV.  So with the information that they make public it’s pretty hard to assess what they’re doing, let alone to what outcome.   And then lastly the Global Fund to Fight AIDS, Tuberculosis and Malaria which was established in 2002 and has approved over $15.1 billion in grant funding since then, it’s the largest external funding of TB programs. It provides roughly a quarter of international support for HIV/AIDS.  Being largely country-driven the Global Fund relies heavily on grantees and agencies providing them technical assistance.  So include TB-HIV activities in both their grants, in their TB grants and in their AIDS grants.  So to a large extent they’re country-driven and then informed by technical guidance.   The guidance coming from the Global Fund secretariat however, sends grantees a pretty weak signal that they need to include TB-HIV.  On the grant application forum that grantees submit to the fund, in fact, the only guidance that recommends TB-HIV activity is included as a footnote.   So we analyzed grant proposals for nine countries in sub-Saharan Africa that together accounted for more than half of all TB-HIV cases in 2006.  And we found that of these nine only $6.8 million was budgeted for TB-HIV in 2008.  And in some cases, proposals planned to carry out activities but then didn’t include any sort of budget line to fund them.   Recently, however, the Global Fund’s board adopted a new policy on TB HIV that calls for projects entering their second phase to include robust and measurable activities in TB-HIV and this showed serious commitment and if implemented properly could address this problem head on.   So I’ll end there with our main findings and I’ll end with just a question that was raised in our research and that’s you know while HIV programs have been rapidly expanding and expanding access to treatment and testing and it’s pretty clear that they haven’t taken the steps needed to address TB-HIV including the infection control measures that are needed to prevent it from spreading in clinical settings, the question arises as to the extent to which these settings where people with weak immune systems are congregating to receive treatment for HIV are actually facilitating the spread of TB which is airborne among people who are immuno-compromised and something that I think Dick touched on and I’ll end with that.   Joanne Carter:  Thanks very much, Paul.  Now, I’d like to ask Dr. Carol Dukes Hamilton to make some remarks on these issues.  Carol is co-chair of the Infectious Diseases Center for Global Health Policy and Advocacy and also a professor of medicine at Duke University.  And Dr. Hamilton has also served as the North Carolina TB Control Medical Director so thanks for being with us and please go ahead.   Carol Hamilton:  Thank you, Joanne and thank you all for joining the call.  Most of what I have to say has already been said in some form, but just to remind you that TB is a contagious lung disease that has been well known and recognized since the 19^th Century, this is not a new disease. And since the 1960s, we’ve had drugs available to cure nearly every case of TB, if the drugs are properly taken.  But now, in 2009 instead of declaring this disease conquered, you’ll be reporting that there were even more cases in 2007 than in 2006, 9.3 million new cases, up from 8.3 million cases in 2000 and 6.6 million in 1990.  And furthermore, the drugs used to treat TB, which have been around since the late 1950s, are getting relatively weaker and weaker against a bacteria that’s basically figuring out how to evade the TB drugs.  So our focus is really on TB-HIV and should be. Another aspect of this that just bears some reminding, 4 years ago colleagues in Tugela Ferry, South Africa made a really alarming discovery.  An extensively drug-resistant strain of TB, so called XDR-TB, unbeknownst to anyone had widely circulated in their rural community in South Africa.  XDR-TB is nearly untreatable with our current arsenal of TB drugs.  XDR-TB had found its way into the TB-HIV co-infected population there in Tugela Ferry and 52 of the 53 people identified with XDR-TB and HIV/AIDS died within 2 weeks of their diagnosis.  They had just started their lifesaving HIV medications, but as has been mentioned before, they died of TB before the HIV drugs could really take effect. So those of us who work in this field are really not shocked to see the estimates of TB-HIV deaths rise as Dr. Chiassen said, the currently used TB diagnostics do not pick up TB very well, especially when used in populations that have HIV infection, and this is a really important area that needs further resources. So add to the diagnostics problem the fact that these drug-resistant TB bacteria are uniquely able to exploit the weakest individuals and the weakest healthcare systems where it can flourish and spread and you’ll see why we’re quite alarmed at the foothold this potentially untreatable form of TB is gaining in China, India, the former Soviet Union and South Africa. So, in addition to the devastation that TB causes among people with HIV/AIDS, its powerful enough to kill even the most able-bodied.  Nearly 1.3 million deaths from TB are among HIV negative men, women and children.  So furthermore, TB can pass easily between people with and without HIV infections, so in countries where TB and HIV/AIDS are prevalent and co-exist it is really an escalating situation and that’s exactly what we’re seeing in sub-Saharan Africa. So, what do we need?  We need U.S. leadership, specifically as already – as Paul and others have discussed, we need TB – we need leadership around the HIV-TB programmatic funding as well as TB research.  We need programs to be able to do the kind of research, public health evaluations, et cetera to really understand what we’re doing in the clinics, and as has been mentioned, a really important issue is the lack of serious attention to infection control, meaning we need to put in place strategies to prevent TB from spreading in that population. The second and final issue I’ll mention has to do with research and TB.  We need increases in NIH budgets to specifically address, for example, TB vaccine development and improving TB diagnostics, and the CDC’s division of TB elimination which funds clinical trials will (try) testing new TB drugs and treatment strategies.  So I’ll end there and be happy to take questions when you’re ready. Joanne Carter:  Thanks so much, Dr. Hamilton. And now lastly, but far from least, we’re really thrilled to have Kenyan TB-HIV patient-activist, healthcare worker, and really, global leader on TB and HIV advocacy Lucy Chesire with us to give us a perspective on the – really, on the ground impact of this latest data and this co-epidemic.  Lucy, please go ahead. Lucy Chesire:  OK, hello.  I guess basically what we’re seeing is that when you look at TB-HIV, its actually a major co-infection within the African continent, and TB has actually been recognized as the leading killer of people living with HIV.  And one thing that we have come to see from experience of implementing TB-HIV collaborative activities is that this has been a missed opportunity for years, but thanks to the funding that we are now seeing though global fund and even PEPFAR, whereby it has made it much, much easier for persons living with HIV to get access to TB treatment.   But I know we still have a challenge when it comes to the issue of diagnosing and screening people living with HIV, but now when you look at the co-infection rates, it actually ranges from 60 percent to about 80 percent in areas where co-infection is much, much higher.  And I guess my motivation on this comes from the aspects whereby I survived TB-HIV co-infection and TB also created the door for me to be able to access and to reach vital therapy and out of that, getting to see the difference that it made in my own life means that this is one thing that we need to work together so that we continue mobilizing resources through the Global Fund, though PEPFAR so that countries are better placed to continuing offering the services so that patients can actually benefit. Looking at the screening of all TB patients for HIV, we are getting amazing results whereby over 80 percent based on the Kenyan experience of TB patients have had access to HIV testing, 60 percent have been confirmed to be HIV positive and currently being referred for treatment and one of the things that we are actually working on is to make sure that at the end of the day, all persons living with HIV are actually screened for TB. Now, when you look at the global statistics, it’s pretty a shame because only 2 percent of persons living with HIV are actually being screened for TB and I guess we need to put more effort when we are looking at the collaborative effort so that we put in measures to be able to address infection control, to be able to intensify case finding among persons living with HIV so that if someone is smear positive they can be able to get access to TB screening and get started on treatment because we know the cost effectiveness of insuring that these services are actually there.  And then most importantly is the issue of infection control whereby measures need to be put in place so that at the end of the day persons are not getting TB within the healthcare facilities where they’re actually accessing their antiretroviral therapy. But I just want to say that investing in TB-HIV and insuring that adequate resources are mobilized, both from the North and the South would actually make a difference in insuring that we get all the patients who need the treatment to be on it at the appropriate time. Joanne Carter:  Thanks, thanks, Lucy, thanks very much.  Operator, we’ll now open it up for questions again.  So if you can just give a quick reminder on how folks can ask questions. Operator:  Thank you.  If you would like to ask a question today, it is star 1 on your touchtone phone.  And once again, that is star 1.  And we will go first to Jon Cohen with Science magazine. Jon Cohen:  Hi, if Dr. Chiassen is still there, this might be most appropriate for him.  Do you know – can you explain why the numbers doubled for co-infection?  What the actual surveillance techniques were that led to the doubling? Male:  Dr. Chiassen – excuse me, he’s left the room.  He had to go to another session. Jon Cohen:  He did leave. Male:  But I’ve got his aides, Claudia’s mobile number here, so we can get that to you so you can connect with him a bit later. Jon Cohen:  Or if anyone else can answer …  Lucy Chesire :  Let me just answer that, if you allow me.  I think when you’re looking at the numbers that doubled, what we are basically seeing is that it became much more accessible for TB patients to be able to accept what we call diagnostic testing and counseling within the healthcare facility which was being rolled out in most of the TB clinics and this has resulted in many patients, getting the testing onsite, despite in the past where by we were losing out on a lot of referrals cases when a patient had to be referred to the voluntary counseling and testing site.  So when the services became readily available, at the TB clinic, it made a big difference and many more patients were able to get to know their HIV status and many of them were actually enrolled on pre-ART care. Paul Jensen:  And then I would just add to that – this is Paul, that in a general sense its maybe because of improved data collection and better participation from countries reporting what they’re collecting, but we can put you in touch with WHO to get a more precise answer. Operator:  And we’ll take our next question from Benjamin Case with Interpress Service. Benjamin Case:  Hi, this question is for Dr. Hamilton.  Just curious, what have been the funding patterns for TB related research and prevention in the U.S. in the past few years and what can we anticipate from the new administration during the economic crisis. Carol Hamilton:  Yes, that’s a very good question and the funding in particular to the CDC, which is where the programs out in the states get their money, has been going down.  Its been going down from 5 to 10 percent and programs have had to cut back on training and education, opening new clinics, et cetera.  So the money has been going down from the CDC for programs. In addition, for TB research, and many people don’t really recognize that the CDC’s TB elimination group is actually the one that is slated to perform any TB clinical trials kind of work, which is different than you know usually we think of the NIH as doing clinical trials work, which they do for HIV/AIDS for example and cancer drugs.  But the CDC does that, performs that function for TB drugs and the TB trials consortium for example and the TB epidemiologic consortium which do important work in the U.S., their budgets have also slowly declined over the last 5 to 7 years. And – did that answer your question? Benjamin Case:  Yes, yes it does.  Thank you. Operator:  And we will take our next question from Brenda Wilson with National Public Radio. Brenda Wilson:  Thank you.  I just want to be clear, when the World Health Organization says that 33 percent of the 9.3 million people who are infected with HIV are co-infected, and only 2 percent of HIV positive people have been screened, is there another estimate or how realistic is that then.  Or am I misunderstanding something? Male:  We’re having trouble hearing on this end in Brazil. Brenda Wilson:  OK, I’ll try asking – I’ll try speaking up louder.  If I understood correctly, WHO says 33 percent of the people with tuberculosis are also infected with HIV and you’re saying that 2 percent of the people with HIV have been screened, so does that 33 percent – is that an estimate which takes into consideration more than the 2 percent who have been screened? Carol Hamilton:  This is Carol Hamilton; let me try to address that.  I think the way you should look at that is out there in the community when we have – in the world when you have somebody who comes in and you recognize that they have tuberculosis, the recommendation is that every patient with TB should be screened for HIV because there’s such a tight connection between the two. But worldwide, the number that really – the number of TB patients that are screened for HIV is only 2 percent.  OK?   Now, of those who are screened, TB patients who are screened for HIV, 33 percent are found to have HIV infections.  Do others agree that that’s the way those numbers go? Male:  Hi, this is … Lucy Chesire:  No, I don’t agree.  I think it’s the other way around where we are saying that 2 percent of persons living with HIV are actually being screened for TB.  And the data from WHO shows that 37 percent of TB patients are actually getting involved on anti retroviral therapy.  But when it goes to the number of patients who are actually being screened, – the number of TB patients being screened for HIV, the numbers vary from – one country to the other.  But on average it’s about 40 to 60 percent globally. Paul Jensen:  Hi, this is Paul, just to hopefully clarify a little bit.  Brenda, that 33 percent refers to the number of people with HIV who have TB infection.  And there are two stages, you could say; one is the latent infection of TB and then the progression of that to actual infectious disease.  And so that one third, that 33 percent refers to the number of people with HIV worldwide estimated will also have a latent TB infection. The 2 percent refers to people who have actually been physically screened and reported to have been screened, and that’s 2 percent of people with HIV who have been reported to be screened for TB disease, not TB infection but TB disease. Brenda Wilson:  OK, thank you. Operator:  And as a reminder if you would like to ask a question today, it is star 1 on your touchtone phone.  And we will take a follow up question from David Brown from the Washington Post. David Brown:  Yes, thanks.  Is the screening for TB a chest x-ray?  Because presumably it’s not a skin test and are there any other screens for – or is it a sputum test or what is it? Paul Jensen:  Yes, it – it would – the screening would entail a sputum test, typically.  And then, from there, a chest x-ray.  It’s also important to keep in mind, it’s a little bit difficult in people with HIV to screen using the sputum test because they often don’t actually produce bacteria in the sputum itself.  A lot of times the TB has disseminated past the lungs and is in another part of the body that doesn’t produce sputum.  But that would be the standard test, the sputum smear test followed by a chest x-ray. Joanne Carter:  And … David Brown:  OK, well– can I just follow up?  The implication when you all say that only 2 percent of people with HIV are being screened for TB is that you know this is an outrage and screening can be done easily and it actually tells you something.  So can you – can you sort of expand on that?  Can it be done easily?  And is it a good way of diagnosing TB?  It sounds like it’s hard to do and it gives you a misleading answer lots of times. Joanne Carter:  I don’t know, Dr. Hamilton, if you want to take that … Carol Hamilton:  Sure. Joanne Carter:  Or we can make some comments here as well. Carol Hamilton:  Sure, I think you raise a really good point.  It is difficult because these diagnostic tests that we have are so insensitive, so you’re raising a very good point.  Nevertheless, if you are able to see the bacteria under the microscope, that does indicate a higher level of infectivity.  So it is helpful.  But even better would be if we had better diagnostics deployed out in these clinics.   So that in fact, you could do sputum and not only just the test where you look under the microscope, but also for culture you know that would be ideal, because we know we have a couple – at least two different studies that have been done in the last year that show that even in patients who have fairly subtle symptoms, HIV patients who have fairly subtle, if no, symptoms, if you actually take their sputum and culture it anywhere from 10 to 25 percent in these high burden countries will be culture-positive for TB.  So we need better diagnostics. Joanne Carter:  And this is Joanne Carter, and I think the only thing that I would add is that I think your questions a really good one and it absolutely points to the need for better diagnostics, especially point of care kind of diagnostics, but that because there is you know the sputum microscopy that is available and even ways to improve that because there is actually a clinical algorithm for diagnosing this, it is more to say that the – it’s not an excuse for inaction.   So we need better diagnostics, but we actually need to sort of maximize the use of the existing tools that we have, which can certainly you know save the majority of lives of people and that that’s – I think part of the outrage is that we’ve known this for a long time and this isn’t happening and you know frankly the resources and the urgency around having the diagnostics you know in the pipeline and ready to be out in the field are also not happening, but just that we can’t use it as an excuse for inaction. David Brown:  Can I ask one more follow up? Joanne Carter:  Of course. David Brown:  If someone is PPD positive and has latent you know TB, latent infection with TB and then they become infected with HIV, do 100 percent of them go on to develop active TB? Carol Hamilton:  If you’re assuming that this HIV infected person or population never gets HIV drugs, never gets antiretrovirals.  The estimate is that 10 percent of that group, their likelihood of going from latent TB infection to disease is 10 percent annually.  So in theory, if they have and lived with HIV for 10 years, the answer would be yes.  In fact, what happens, hopefully is that they get – there’s an intervention with antiretrovirals, but if not, then it is – you know I don’t know that anyone can say it’s 100 percent, but you know if you do the math, 10 percent per year it’s very high. David Brown:  OK, and but if they get anti retroviral treatment and no TB treatment they still go on to die of TB, isn’t that what Dr. Chiassen was saying? Carol Hamilton:  Well, if you start – if they have only latent TB infection and they’ve not progressed on to active disease and they get started on anti retrovirals, their CD4 counts go up and you’ve gotten them before they progress to disease, then no, not necessarily.  So we still would like to give those people preventive therapy, but a the CD4 count goes higher and higher, then they kind of move out of that extremely high risk phase, if you see what I mean.  If they stayed down in that low CD4 count area then they are at extremely high risk.  With anti retrovirals their risk becomes somewhat lower, but it is true that we try to give them isoniazid and preventive therapy to – even while we’re giving them anti retrovirals. David Brown:  OK, thanks. Joanne Carter:  And it is worth noting – back to the point Dr. Hamilton made earlier about the case in Tugela Ferry, that you know again, I think the thing that was very worrisome to folks was the spread of that XDR-TB, but the fact that it actually happened in part and was initiated in part in an antiretroviral support group.  So it was folks that actually were on ARVs so to that point of it certainly doesn’t – it reduces risk but it certainly doesn’t eliminate it. David Brown:  OK, thanks. Operator:  Follow up question from Benjamin Case with Inter Press Service. Benjamin Case:  Hi, again.  Sorry, this is just following up first of all on my previous question, I neglected to press a little further about what we can expect from the new administration now, or what we can predict from the new administration about TB funding for the CDC or if there’s any basis on which to make that determination right now. Joanne Carter:  I don’t know, Dr. Hamilton, if you have a better sense.  I don’t think – I mean I think we’re all awaiting to see the details on this.  I mean, I think its – I think we’re hopeful that there would be increased investments and there certainly ought to be and worried about whether you know they would be – any of these would be a consequence of the – of some of the budget cuts that are going to need to happen. Carol Hamilton:  What – and what I do know is that in the recent stimulus package that was announced, the CDC is getting very little money and the money they’re getting, none of it is going to the TB program at all.  In terms of the NIH budget, the NIH budget has gone up significantly and there’s not – there’s not too much in there that is too much – specifically addresses TB research issues, but there is some.  So that’s why I know thus far.  Now … Joanne Carter:  Yes, sorry, go ahead. Carol Hamilton:  I was just going to say, the second issue has to do with PEPFAR funding and a big issue is concern about whether or not the administration is going to continue to not only – to fund PEPFAR at an increasing level, which is what’s needed to both support people already on anti retrovirals as well as expand program as needed.  So you guys can probably respond more to that. Joanne Carter:  No I th