Ambassador Mark Dybul’s Remarks on the Global Response to HIV and Tuberculosis, HIV-TB Global Leaders' Forum Panel

Ambassador Mark Dybul, PEPFAR Coordinator
Remarks on the Global Response to HIV and Tuberculosis, HIV-TB Global Leaders' Forum Panel
UN Headquarters
June 9, 2008

The United States applauds the leadership of Secretary-General Ban Ki-Moon, President Sampaio, and President Kerim in convening this historic meeting. As we have just heard in compelling detail, the dual threat posed by HIV/AIDS and tuberculosis is nothing less than alarming. The goal of this panel is to discuss what we will do to respond to this challenge.

Global STOP TB Strategy
First, we need to recognize that we already have the tools we need to turn the epidemic around. We have long known that controlling TB is effective and relatively inexpensive, but the emergence of an HIV-driven TB epidemic outstripped the capacity of even the most well-organized TB programs to respond.

The Global Plan to Stop TB, launched by the STOP TB Partnership in 2006 in part as a response to this HIV-fueled epidemic, is designed to achieve the Millennium Development Goal of halting and reversing TB incidence by 2015. The strategy also calls for addressing HIV/TB and MDR-TB, strengthening health systems, and empowering communities and patients.

Global responses to HIV/TB
One concrete step that we must prioritize is adoption and full implementation of an HIV/TB package of activities as part of scale-up of HIV prevention, treatment and care programs. As we have said, the link between HIV and TB is a grave threat, but it also provides us with an opportunity. Over the past few years, we have seen massive investments in international health programs as part of a new era in development, in which we move past the old donor-recipient model into a new model of partnerships between equals. These partnerships are enabling us, for the first time in history, to build the infrastructure we need to care for chronic disease, and we must make sure that the chronic care infrastructure built for HIV is used to respond to TB and other diseases.

How we do this will vary significantly by country, though, because we need to remain sensitive to the details on the ground. Just two weeks ago, I was in the Democratic Republic of the Congo. There, they have mounted a strong response to TB, and HIV/AIDS programs will do well to build on top of the existing TB programs. In other countries, the HIV/AIDS programs have seen great success, while TB programs may have lagged, and there we would do well to build the TB response on top of our HIV programs. But what is clear is that that both programs have critical roles to play in planning and implementing HIV/TB services for the clients they serve.

WHO recently organized an important global consultation that put these issues of collaboration firmly front and center. The so-called Three “I”s meeting focused on three priority activities for responding to HIV/TB: isoniazid preventive therapy, intensified TB casefinding, and TB infection control. This meeting was a huge step forward in actively engaging the HIV community to take ownership of these activities; now we need to take the progress we’ve made at an international meeting and translate it into rapid scale-up at the country level.

One key player in this effort will be the Global Fund, ably represented here today, which has committed $1.4 billion to TB grants through 2007. Approximately 30 percent of this funding is provided by the United States, which also supports provision of technical assistance to Global Fund TB grants through the Stop TB Partnership.

In addition to support for the Global Fund, the United States also provides support for the WHO (both the STOP TB and HIV Departments) as well as the Green Light Committee for multi-drug resistant TB, which supports a variety of interventions aimed at strengthening TB control as well as preventing, detecting, and treating drug-resistant TB. Funding for technical assistance supports countries’ ability to develop applications to the Green Light Committee and supports country programs to improve their capacity to provide treatment for MDR-TB. We also work with the World Bank, UNAIDS, the International Union Against TB and Lung Disease, and the private sector.

I also was very glad to see the formation of the Global Laboratory Initiative (GLI) in WHO recently, because the lack of diagnostic capacity is a significant barrier to our response to the challenges of TB/HIV and drug-resistant TB. A massive scale-up of integrated HIV and TB laboratory services is an essential step in effectively addressing the diagnostic challenges of HIV/TB and MDR-TB.

In cooperation with our international partners, the U.S. Government has demonstrated a historic commitment as well. HIV/TB activities are a priority for PEPFAR, which has increased its funding for HIV/TB more than five-fold from 2005 to this year, from $26 million to approximately $150 million. That money is being put to good use; by the end of September 2007, PEPFAR had supported care for more than 367,000 TB/HIV co-infected people in the 15 PEPFAR focus countries.

One particularly compelling example of what we can achieve when we work together is PEPFAR’s collaboration with the WHO in three countries. Through this partnership work in Kenya, 84 percent of TB patients were tested for HIV by the second quarter of 2007, up from 41 percent; in Rwanda, 88 percent of TB patients were tested, up from 45 percent.

Through the same PEPFAR-WHO collaboration, 42 percent of HIV-positive TB patients identified in Kenya were started on ART by the end of 2007; in Ethiopia, 28 percent of HIV-positive TB patients received ART by mid-2007, up from a baseline of 19 percent; and in Rwanda, 36 percent of HIV-positive TB patients received ART by the end 2007 from a baseline of 13 percent.

PEPFAR is also expanding our partnerships with the Bill and Melinda Gates Foundation. A country planning workshop held in Washington in March 2007 yielded costed TB/HIV scale-up plans and additional PEPFAR funds to rapidly begin implementation. Follow-up consultations were held in Kigali last year, and PEPFAR and Gates plan to continue collaboration in field-level interventions that leverage the capacities of each.

Most important of all, though, are the people living in affected communities around the world who are working to address the threat of HIV/TB. As with the response to HIV, a successful response to TB must be country-owned, led by the people of heavily-affected communities. These local leaders must advocate and educate in support of activities such as proper cough etiquette, health-seeking behaviors, and safe environments in clinics and hospitals. International partners like PEPFAR, WHO and the Global Fund can and must come alongside to support them, but we must remember the vital importance of country ownership to an effective response.

Thank you for your engagement and partnership on this important issue.