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  TB/HIV Coinfection Mobilization Workshop
  A Report from the Treatment Action Group (TAG)
  TB/HIV Coinfection Education & Community
  Mobilization Workshop
  A Satellite Meeting Held in Conjunction with
  the STOP TB DOTS Expansion Working Group &
  The 33rd International Union Against Tuberculosis
  & Lung Diseases (IUATLD) Conference

  Montreal, Quebec, Canada
  5 October 2002

  by Daniel Raymond
  edited by Mark Harrington

  Treatment Action Group
  611 Broadway, Suite 608
  New York, NY 10012 USA

  Credits & Acknowledgments
  Daniel Raymond is an independent contractor in New York City who writes on a variety of AIDS-related research, treatment
  and policy issues. He was the coordinator for the TB/HIV Coinfection & Community Mobilization Workshop. He can be
  contacted at daniel.raymond@verizon.net.

  Mark Harrington is Executive Director of Treatment Action Group (TAG) in New York City.

  The Treatment Action Group (TAG) fights to find a cure for AIDS and to ensure that all people living with HIV receive the
  necessary treatment, care and information they need to save their lives. TAG focuses on the AIDS research effort, both public
  and private, the drug development process, and our nation's health care delivery systems. We meet with researchers,
  industry, and government officials, and resort when necessary to acts of civil disobedience, or to acts of Congress. We strive
  to develop the scientific and political expertise needed to transform policy. TAG is committed to working for and with all
  communities affected by HIV.

  Acknowledgments.
  We are grateful to Gerald Friedland for first suggesting - back in 1997 when TAG first released our Opportunistic Infections
  (OI) Report, version 1.0 – that we needed to address tuberculosis in the context of HIV infection. The TB/HIV Coinfection
  Education & Community Mobilization Workshop was made possible by a generous grant from the Office of AIDS Research
  (OAR), Office of the Director (OD), National Institutes of Health (NIH). First thanks go to the Steering Committee members
  who provided excellent advice; to the participants, presenters and moderators; to Nils Billo of the IUATLD for arranging
  registration to the IUATLD conference for workshop recipients; to John Beach of John Beach Travel; and to David Thompson
  of the Canadian HIV/AIDS Legal Network, who provided great on-site logistical support. Additional thanks to the board, staff,
  consultants and donors who support and carry out the work of the Treatment Action Group, and particularly to TAG's
  administrator, Will Berger, without whom the workshop would not have been the success it was. Finally we would like to thank
  Arata Kochi, Paul Nunn and Mario Raviglione of the World Health Organization (WHO) for challenging us that "tuberculosis
  needs its own ACT UP".

  Contact us. If you would like more information about TAG, contact us at:

  Treatment Action Group
  611 Broadway, Suite 608
  New York, NY 10012 USA
  212.253.7922 p / 212.253.7923 f
  tagnyc@verizon.net | www.treatmentactiongroup.org

  Suggested citation. D Raymond. A report from the TAG TB/HIV coinfection & community mobilization workshop, Montreal, 5
  October 2002. M Harrington, ed. Treatment Action Group (TAG), New York, USA, December 2002.




  TB/HIV Coinfection Education and Community
  Mobilization Workshop


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  A Satellite Meeting Held in Conjunction with
  the STOP TB DOTS Expansion Working Group &
  The 33rd International Union Against Tuberculosis & Lung Diseases
  (IUATLD) Conference

  Montreal, Quebec, Canada – 5 October 2002

  Executive Summary
  Workshop Composition & Format
  On October 5, 2002, Treatment Action Group (TAG) sponsored a TB/HIV
  Coinfection workshop in Montreal attended by 29 people. Eighteen participants
  were from the developing world, principally from sub-Saharan Africa, but also from
  Brazil, eastern Europe and India.

  Participants were recruited from countries with high HIV prevalence and
  tuberculosis incidence. Applicants were prioritized according to their work in HIV
  and/or TB, involvement at community level, and history of advocacy activities. The
  workshop generated a great deal of interest. TAG was only able to accept less than
  a quarter of the applications. Presenters and moderators were drawn from public
  health agencies, including WHO and the CDC, and groups with successful histories
  of community mobilization and advocacy.

  The workshop included presentations on tuberculosis epidemiology, natural history,
  and treatment; HIV disease and treatment; strategies for coordinating TB and HIV
  medical care and services; and community mobilization models and strategies.
  Participants broke out into four small groups to discuss opportunities and
  challenges in addressing TB/HIV coinfection in their countries.

  In the days following the workshop, participants attended the 3rd Stop TB DOTS
  Expansion Working Group public meeting and TB-related sessions at the 33rd
  International Union Against Tuberculosis and Lung Diseases (IUATLD) conference.
  Before returning home, participants met to share what they had learned and to
  discuss plans for follow-up.

  Follow-up Ideas & Plans

    1. Botswana – working with a network of ASOs to develop a community
       mobilization plan on TB/HIV coinfection; discussing TB/HIV at October NGO
       meeting.
    2. Brazil – planning with Rio de Janeiro TB control program and IUATLD for a
       regional TB/HIV meeting in 2003.
    3. Estonia/Eastern Europe – incorporating TB into HIV trainings and meetings.
    4. India – working with the Network of Maharashtra PLWHAs on promoting TB
       screening for HIV infected individuals, disseminating information to community
       members on TB/HIV coinfection; identifying needs for information, education
       and communication (IEC) materials, including translations of existing
       information.
    5. Kenya — developing a proposal for community mobilization around early TB



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       diagnosis and treatment; working on planning a TB/HIV component for the
       13th ICASA meeting in September 2003.
    6. Malawi — developing a plan for isoniazid (INH) and cotrimoxazole prophylaxis
       through a home based care program; planning to integrate TB and HIV care
       (including HAART) at the district level; creating an action plan for a
       coordinated country-level response to TB/HIV and consulting with other TB
       and HIV clinicians and researchers.
    7. Zambia – holding a TB/HIV concert event attended by 400 students at a
       teachers college; initiating weekly outreach activities on TB/HIV coinfection;
       planning a four-day workshop to train outreach workers on TB/HIV
       coinfection; incorporating TB/HIV health education into a research project on
       delays in TB diagnosis and initiation of treatment.

  Workshop participants will stay in contact through an email list designed to
  encourage information sharing and the discussion of strategies. TAG will track the
  on-going activities of workshop participants and provide support and feedback on
  advocacy efforts.

  TB/HIV Coinfection Education and Community Mobilization Workshop

  Introduction and Background
  In recent years the link between tuberculosis and HIV has gained incReasing
  attention. TB accelerates HIV progression, and HIV increases the risk of developing
  active TB disease. The global TB and HIV epidemics fuel each other, and together
  make up the leading infectious causes of mortality around the world. Conventional
  TB control efforts are inadequate in high HIV prevalence countries, and TB is a
  leading cause of mortality in people with HIV.

    1. 11% of all new adult TB cases were attributable to HIV infection in 2000 - in
       Africa the figure is 31%.
    2. Of 1.9 million deaths from TB in 2000, 18% were attributable to HIV.
    3. TB was the immediate cause of 15% of all adult AIDS deaths in 2000, of
       which only about one third received TB treatment.
    4. TB/HIV co-infection rates exceed 5% of the adult population in nine African
       countries.

  —An Expanded DOTS Framework for Effective Tuberculosis Control, Stop TB/WHO, 2002


  After years of approaching TB and HIV through "a dual strategy for a dual
  epidemic," the World Health Organization has recently begun to promote its
  "Strategic Framework to Decrease the Burden of TB/HIV". WHO and the Stop TB
  Partnership have established a TB/HIV Working Group, which is acting—through
  projects such as the ProTEST initiative—to develop better models for dealing with
  TB/HIV coinfection. Public health officials, researchers, and advocates are calling
  for increased coordination between national TB and HIV control programs, but few
  models exist and many operational questions have been raised. Moreover, TB and
  HIV programs in high incidence countries are each struggling to mobilize resources
  to expand DOTS coverage and HIV care, including antiretroviral therapy.




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  However, a number of recent developments point to new opportunities:

        Increased international donor support—particularly with stablishment of the
        Global Fund to Fight AIDS, TB and Malaria—has begun to address resource
        gap.
        Increased research efforts - including the CREATE initiative led by the Johns
        Hopkins Center for TB Research - are being initiated to help clarify some of
        the clinical and operational issues.
        Within the Stop TB Partnership, a new emphasis on information, education,
        and communication (IEC) activities and on social mobilization has begun to
        identify ways to develop community-level projects to augment TB and HIV
        control efforts.

  To date, there has been very little education or social mobilization concerning
  TB/HIV coinfection. While a large and growing network of HIV advocates and
  service organizations have mobilized around AIDS, TB has no comparable
  grassroots infrastructure, and has not hitherto been a focus of most HIV groups.

  Planning
  TAG's TB/HIV Coinfection Education and Community Mobilization Workshop was
  conceived as the first step of a broader HIV and TB community mobilization effort to
  take advantage of a unique historical moment in the course of the two epidemics.
  TAG began planning the workshop in the spring of 2002, envisioning it as an
  opportunity to bring together people working in communities in countries struggling
  with severe TB and HIV epidemics. The objectives of the workshop were:

    1. To educate patient community representatives on the various aspects of
       TB/HIV coinfection research, prevention, care and treatment.
    2. To empower patient community representatives to mobilize and disseminate
       information to their local communities.
    3. To give patient community representatives the skills necessary to understand
       clinical trials and provide community input into research and operational
       programs.
    4. To begin the creation of an ad hoc international TB/HIV community advisory
       board to assist the WHO STOP TB TB/HIV Working Group and its Advocacy
       and Communications Working
    5. To introduce patient community representatives to country NTP program
       officers, WHO, CDC, and NIH officials and regional officers so that they may
       work together to implement future TB/HIV initiatives.

  TAG assembled a broad-based Steering Committee (see attached list of members)
  that met in June 2002 just before the 4th World TB Congress in Washington, D.C.
  The steering committee worked with TAG to map out a plan for the workshop, to be
  held as a satellite of the 33rd IUATLD conference in October 2002. The Steering
  Committee continued to advise TAG throughout the processes of publicizing the
  workshop, requesting applications from potential participants, selecting participants,
  developing a program for the workshop, and identifying speakers. TAG provided
  funds for travel and accommodations to workshop participants from the developing
  world — principally from sub-Saharan Africa, but also representing Brazil, eastern



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  Europe and India.

  Participants
  Twenty-nine people attended the workshop, including participants, presenters and
  moderators. Participants were selected based on representation of patient groups,
  experience in community work, and disease burden in country of origin. Interest in
  the meeting was considerable, and fewer than 25% of applicants were chosen to
  attend. Unfortunately, some invited participants were unable to attend due to health
  problems or last-minute visa difficulties. The workshop was also attended by
  participants from Canadian groups, including the Canadian HIV/AIDS Legal
  Network and the Montreal Public Health Department, and a Norwegian patient
  group working with organizations in the developing world (Norwegian Heart and
  Lung Association). Speakers included representatives from AIDS community
  groups in Brazil, southern Africa, Europe and the U.S.A., along with the U.S.
  Centers for Disease Control and Prevention (CDC), and the Stop TB program of the
  World Health Organization (WHO). Following the workshop, participants attended
  the Stop TB DOTS Expansion Working Group meeting and the 33rd IUATLD
  conference following the workshop, and met with TB control program
  representatives from their countries and regions.

  Workshop Presentations & Discussions

  Tuberculosis & HIV Co-infection
  —Dr. Kenneth Castro, Division of Tuberculosis Elimination, CDC, Atlanta, GA, USA
  Dr. Castro began the morning presentations with an overview of TB in the context
  of HIV infection. He began by noting the interactions between TB and HIV:

        TB enhances/accelerates
        —replication of HIV
        —HIV disease progression
        HIV increases
        —risk of active TB
        —mortality after TB treatment
        —resistance to TB drugs
        Treatment for either improves the outcome for the other.

  Dr. Castro reviewed data indicating that TB is a leading cause of HIV-related
  mortality, and that the HIV epidemic in high prevalence countries is driving higher
  TB incidence and death. He outlined the World Health Organization's DOTS model
  (Directly-Observed Therapy, Short-course) for TB control:

        Government commitment to TB control
        Microscopy-based passive case-finding
        Standardized short-course chemotherapy under Directly-Observed Treatment
        Secure supply of quality drugs
        Case registry, monitoring, and evaluation

  Dr. Castro discussed the course of TB disease, including clinical manifestations




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  more common in people co-infected with HIV, such as extrapulmonary disease,
  possibly paucibacillary pulmonary TB, and atypical chest radiographs with fewer
  cavitary lesions. He noted that HIV has been associated with higher frequencies of
  multi-drug resistant TB (MDR-TB). Using case reports, Dr. Castro discussed
  treatment challenges in people with HIV (PWHIV) who have active TB disease.
  While relapse rates are low among coinfected people treated for TB under DOTS,
  early mortality is high – sometimes due to late diagnosis of TB or to other AIDS-
  related comorbidities. Among people with TB disease, highly active antiretroviral
  therapy (HAART) may sometimes induce paradoxical reactions in people with TB
  infection, which include a temporary worsening of symptoms and lesions. In
  addition, many anti-HIV medications interact with rifamycin drugs (rifampin and
  rifabutin) used to treat TB, reducing their efficacy or increasing their toxicity.

  Dr. Castro reviewed the recommended medical evaluation for people with HIV
  suspected of having TB, and outlined treatment options, including
  recommendations for pregnant women, children and patients with extrapulmonary
  TB. He discussed options and indications for treatment of latent TB infection in
  PWHIV and addressed clinical management of paradoxical reactions.

  Dr. Castro outlined lessons from TB control for HIV strategies:

        Cure … Victory
        Treatment = Prevention
        Access to essential drugs is crucial
        Adherence is key
        Drug resistance must be prevented

  He concluded by offering some current questions requiring attention and research:

        What are the best methods to rule out active TB when considering isoniazid
        preventive therapy (IPT)?
        What is the best short course regimen for preventive therapy? What options
        are available where lab capacity for drug susceptibility testing is limited?
        How can we improve on mechanisms ensuring an adequate drug supply,
        proper surveillance, and program coordination?

  Discussion following Dr. Castro's presentation focused on TB exposure risks to HIV
  infected or uninfected health care workers treating people with HIV in high TB
  burden settings; patient and health care provider education; identifying and
  managing paradoxical reactions; the use and availability of IPT; the role of sputum
  samples and chest x-rays in TB diagnosis and the diagnosis of extrapulmonary TB
  (ETB); and the relation of MDR-TB to HIV infection.

  The History, Natural History, & Treatment of HIV Infection
  —Mark Harrington, Treatment Action Group (TAG), New York, NY, USA
  Mark Harrington provided background on the epidemiology and course of HIV
  disease and the impact of antiretroviral treatment on natural history. He reviewed
  data on the origins and spread of HIV, and outlined the natural history of AIDS from




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  transmission to primary infection, chronic infection, progressive infection and AIDS.
  He discussed common opportunistic infections (OIs) and the evolution of HIV
  treatment in the United States from the era of OI prophylaxis and antiretroviral
  monotherapy through to the discovery and validation of HAART and the
  development of current US and WHO guidelines for use of ART in developed and
  resource poor settings, respectively.

  WHO recommendations for initiating therapy in adults & adolescents with HIV
  infection:

  If CD4 testing available:

          WHO stage IV disease [clinical AIDS] irrespective of CD4 cell count
          WHO stage I, II or III with CD4 cell counts below 200/mm3

  If CD4 testing unavailable:

          WHO stage IV disease irrespective of total lymphocyte count [TLC]
          WHO stage II or III disease with a TLC below 1200/mm3

  –Scaling Up Antiretroviral Therapy in Resource-Limited Settings: Guidelines for a Public Health Approach, WHO, April 2002—
  Table A, p. 12


  Mr. Harrington noted the benefits and limitations of current HAART regimens,
  including reduction of AIDS infections and prolongation of life, difficulties with
  adherence, resistance and toxicity, high pill burden, impact on quality of life, and
  cost. He reviewed the April 2002 WHO guidelines for use of antiretrovirals in people
  with active TB disease.

                Antiretroviral therapy for individuals with tuberculosis co-infection
  Situation                          Recommendations
  Pulmonary TB [PTB] and CD4 count           Start TB therapy. Start one of these ARTs as soon as TB therapy is tolerated:
  <50/mm3   or extrapulmonary TB             • AZT/3TC/ABC
                                             • AZT/3TC/EFZ
                                             • AZT/3TC/SQVr
                                             • AZT/3TC/NVP
  PTB and CD4 50-200/mm3 or TLC below        Start TB therapy. Start one of these regimens after completing 2 months of TB
                                             therapy:
  1200/mm3                                   • [Same four regimens]
  PTB and CD4 >200/mm3 or TLC >              Treat TB. Monitor CD4 counts if available. Start ART according to HIV
                                             symptoms, CD4 or TLC as in table A [adults] or B [children]
  1200/mm3
  AZT = azidothymidine (zidovudine), 3TC = lamivudine, ABC = abacavir, EFZ = efavirenz, SQVr = saquinavir + low-dose
  ritonavir, NVP = nevirapine.


  —Scaling Up Antiretroviral Therapy in Resource-Limited Settings: Guidelines for a Public Health Approach, WHO, April 2002 -
  Table G, p. 21


  Mr. Harrington reviewed recent studies indicating that HAART reduces the risk of
  TB disease by 80%, and provided a brief history of global treatment access activism
  and its impact on prices for antiretroviral therapy. He concluded by pointing to future
  directions in TB/HIV policy and laid out some urgent research priorities.




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        Integrate TB & HIV control programs.
        Earlier case detection and treatment of TB in HIV infected persons.
        Study use of HAART in HIV infected persons with TB disease.
        When to treat TB in HIV? Treat TB first, or treat TB/HIV together?
        Which regimens are best in coinfection?
        Use of directly observed therapy (DOT) for HAART?
        Develop more potent, less toxic, faster acting anti-TB drugs and regimens.
        Develop faster, cheaper point-of-use tests for diagnosis of TB in HIV+ people.
        Develop faster, cheaper tests for detection of drug-resistant TB strains.
        Develop better TB vaccines.

  Discussion following Mr. Harrington's presentation focused on diagnosis and
  management of side effects of HAART, the role of education and support in
  adherence to HAART regimens, the prospects for expanding mother-to-child-
  transmission prevention (MTCTP) programs to incorporate on-going treatment for
  families (MTCT-Plus), and guidelines for HAART use in children with HIV.

  A Framework for Access to TB/HIV Prevention and Care
  - Dr. Dermot Maher, Stop TB Department, World Health Organization, Geneva,
  Switzerland
  Dr. Dermot Maher concluded the morning presentations with a description of
  WHO's "Strategic Framework to Decrease the Burden of TB/HIV". Noting that at
  least one in three people with HIV will develop active TB disease, Dr. Maher
  reviewed available interventions against TB and HIV and identified points in the
  course of the diseases which provide opportunity for a unified health sector
  strategy. Dr. Maher discussed an "expanded scope of new strategy to control TB in
  high HIV prevalence populations".

    1. Intensified TB case-finding and treatment
    2. Additional measures beyond TB case-finding and treatment
       –TB preventive therapy
       –Interventions to decrease morbidity and mortality in HIV-infected TB patients
       –Interventions to decrease HIV transmission
       –ARV therapy

  He assessed the current state of implementation of available interventions, noting
  that existing condom distribution efforts were inadequate for HIV prevention, only
  30,000 PWHIV in Africa were receiving HAART, and the majority of countries with
  HIV prevalence rates greater than 5% had not achieved WHO's target of 85% cure
  rates for TB. Finally, he suggested models for TB and HIV control program
  collaboration, including joint activities involving planning, surveillance, staff training,
  drug supply chain management and related logistics, and case detection and
  management. Dr. Maher noted recent increases in aid to global diseases of poverty
  and in research on implementation, concluding that a combination of commitment,
  resources, and action will produce results.

  Community Mobilization Panel Discussion
  –Farai Mugweni, Southern African Network of AIDS Service Organizations



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  (SANASO), Harare, Zimbabwe
  –Rob Camp, European AIDS Treatment Group (EATG), Barcelona, Spain
  –Ezio Santos-Filho, Grupo Pela VIDDA, Rio de Janeiro, Brazil

  Farai Mugweni began the panel discussion with a description of the mission and
  structure of SANASO, noting that the network includes over 1000 organizations in
  the Southern African region. Organizations represent groups working on prevention,
  voluntary counseling and testing, home-based care, orphan support, operational
  research, skills training, and advocacy. SANASO works to develop networks at
  country level, coordinate communication and information sharing, and spur political
  commitment.

  Rob Camp discussed the experience of the EATG in conducting treatment
  education training meetings with international patient and consumer groups. He
  noted the role of the European Consumer Advisory Board (ECAB) in meeting with
  pharmaceutical companies and academic researchers, and in providing input into
  research and trial design, expanded access, drug pricing, and implementation of
  treatment guidelines.

  Ezio Santos-Filho described Brazil's experience with implementing antiretroviral
  therapy, noting that from the perspective of community advocacy, Brazil has been a
  victim of its own success. Widespread availability of HAART has led to a "social
  demobilization" similar to that seen in earlier decades around tuberculosis,
  presenting new challenges in addressing persistent gaps in quality of and access to
  treatment.

  Following the panel discussion, workshop participants divided into four groups,
  moderated by Ms. Mugweni, Mr. Camp and Mr. Santos-Filho, David Barr, and
  Winstone Zulu. Group discussion focused on questions around strengthening and
  coordinating TB and HIV care and services on local, country, and regional levels.
  Groups raised a number of issues and suggestions:

        Utilize World TB Day to raise awareness.
        Lobby local political and community leaders, and work with doctors and
        nurses.
        Link TB with HIV educational activities.
        Increase the awareness of and perception of TB risk among people with HIV.
        Organize country-level meetings of all TB and HIV stakeholders.
        Strengthen the health care system through training, human resources and
        drug procurement.
        Conduct operational research on program coordination.
        Develop training for educators and health care providers.
        Address HIV- and TB-related stigma and delays in seeking treatment.
        Focus on political will and resources, and address issues of good governance
        and accountability and transparency.
        Exploit existing TB infrastructures for drug procurement and supply
        management to build out antiretroviral access.
        Involve NGOs in applications to the Global Fund to Fight AIDS, TB and



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        Malaria.
        Use regional HIV meetings and conferences as further opportunities to
        discuss the links between TB and HIV.
        Develop programs and strategies to work with drug injectors and prisoners.

  Community Mobilization Overview
  –Kraig Klaudt, Massive Effort, Geneva, Switzerland
  Kraig Klaudt concluded the workshop by presenting a model for planning
  community mobilization campaigns around TB and HIV. He stated that community
  mobilization efforts can have two goals and two audiences.

    1. Changing social/political behavior by creating a cause—policy-makers and
       donors
    2. Changing risk group behavior by focusing on people—individuals and at risk
       or affected communities

  Mr. Klaudt outlined approaches to developing community mobilization strategies,
  citing historical examples as well as several examples from TB and HIV. He
  proposed a four part process.

    1. Documentation: Identify and research a problem, providing data and statistics.
    2. Agenda setting: Create and market a solution to respond to the problem.
    3. Coordination: Bring in partners and provide measurable targets and
       outcomes.
    4. Social mobilization: Expand the focus to community-level work and foster
       global advocacy.

  Mr. Klaudt noted that WHO views social mobilization as an essential part of
  achieving success in realizing the WHO targets for TB case detection and cure
  rates under DOTS. He described initial steps taken by WHO and others to address
  community mobilization, and cited the historic opportunity of linking TB mobilization
  with existing successful and ongoing community mobilization efforts around HIV. He
  identified several components of successful social mobilization efforts, including
  offering activities accessible to the public, creating iconic symbols—such as the red
  ribbon for AIDS awareness—and identifying measurable targets for desired results.
  He emphasized the critical role of the media, citing data suggesting that in the
  United States, AIDS funding and TB funding have each followed patterns
  corresponding to the amount of newspaper, radio, and television coverage these
  diseases have received. Following the presentation, participants discussed ideas
  and examples for adapting these models to TB/HIV mobilization activities.

  3rd DOTS Expansion Working Group & 33rd IUATLD Conference
  Following the workshop, participants attended the 3rd DOTS Expansion Working
  Group public meeting on October 6, and the 33rd International Union Against
  Tuberculosis and Lung Disease (IUATLD) conference from October 7-9. The
  conference featured several sessions on TB/HIV coinfection. In addition, workshop
  participants met with various officials, including national TB program coordinators,
  and with Dr. Richard Feachem, executive director of the Global Fund to Fight AIDS,




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  TB and Malaria. Participants also met as a group throughout the conference to
  discuss presentations they attended, identify key areas of concern and talk about
  plans for using the information and discussions from the workshop in follow-up
  activities back home.

  Follow-Up Ideas, Activities & Plans
  Workshop participants reconvened for a final meeting to discuss follow-up activities.
  A number of suggestions and strategies were proposed.

         Organize similar workshops on a regional level; the 13th International
         Conference of HIV/AIDS and Sexually Transmitted Infections in Africa
         (ICASA) in Nairobi, Kenya in September 2002 was proposed as an ideal
         setting.
         Develop a training of trainers at country level to disseminate information on
         TB/HIV coinfection.
         Adapt educational materials to local languages and cultures.
         Integrate TB into HIV education.
         Use existing educational groups to mobilize community members around TB
         advocacy issues (early diagnosis, INH prophylaxis, reducing stigma, etc.).
         Meet with NTP and NACP program managers to discuss program
         coordination.
         Advocate for joint TB/HIV strategies within Country Coordinating Mechanisms
         (CCMs).

  Workshop participants will stay in contact through an email list designed to
  encourage information sharing and the discussion of strategies. TAG will track the
  on-going activities of workshop participants and provide support and feedback on
  advocacy efforts.

  Evaluation & Results
  Workshop participants completed a brief written evaluation addressing the following
  questions:

    1.   What did you learn during the workshop?
    2.   Besides information, what else did you get out of participating?
    3.   How will you use this knowledge and experience in your work?
    4.   How could we improve the workshop?

  Participants overwhelmingly called the workshop a success, felt the format and
  content were useful and appropriate, and learned from every presentation.
  Participants also appreciated the opportunities for group discussion and the chance
  to network with each other and with other IUATLD attendees from their countries
  and regions.

  There was a strong desire among participants for a follow-up meeting or workshop.
  Participants also recommended that future workshops attached to conferences
  should work with conference organizers to include a speaker or session on social
  mobilization. Suggestions for future versions of the workshop focused on the



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  possibility of doing longer workshops with added discussion time and training
  exercises.

  Ongoing & Planned In Country Follow-Up Activities
  Within a month after the workshop, participants have reported the following
  activities and plans:

        Botswana—Pedzisani Motlhabane from BONASO is working with a network of
        ASOs to develop a community mobilization plan on TB/HIV coinfection, and
        discussed TB/HIV at an October 2002 NGO meeting.
        Brazil—Ezio Santos-Filho from Grupo Pela VIDDA and the TB Control
        Program/RJ-MSH is planning a regional TB/HIV meeting in 2003 in
        conjunction with the Rio de Janeiro TB control program and the IUATLD.
        Estonia/Eastern Europe—Andrej Kastelic from IHRD is working on
        incorporating TB into HIV trainings and meetings around the region.
        Kenya—Ludfine Opudo from SWAK is developing a proposal for community
        mobilization around early TB diagnosis and treatment. Dorothy Onyango from
        WOFAK is working on working on planning a TB/HIV component for the 13th
        International Conference on HIV/AIDS and Sexually Transmitted Infections in
        Africa (ICASA) in Nairobi in September 2003.
        India—Manoj Pardesi from the Network of Maharashtra PLWHAs is working
        with his network on promoting TB screening for HIV infected individuals,
        disseminating information to community members on TB/HIV coinfection and
        identifying needs for IEC materials, including translation of existing
        information.
        Malawi—Leopold Buhendwa from MSF-L/Thyolo is developing a plan for INH
        and cotrimoxazole prophylaxis through a home based care program; planning
        to integrate TB and HIV care (including HAART) at the district level; creating
        an action plan for a coordinated country-level response to TB/HIV and
        consulting with other TB and HIV clinicians and researchers.
        Zambia—Winstone Zulu, Kara Counseling & Training Trust will be holding a
        TB/HIV concert event attended by 400 students at a teachers college;
        initiating weekly outreach activities on TB/HIV coinfection; planning a four-day
        workshop to train outreach workers on TB/HIV coinfection. Amos Nota from
        ZAMBART is working on incorporating TB/HIV health education into a
        research project on delays in TB diagnosis and initiation of treatment.

  Summary & Conclusions
  The workshop was very successful at bringing together patient community
  representatives, providing a solid foundation of TB/HIV knowledge, fostering
  discussion and networking, and promoting post-workshop education and social
  mobilization activities. The workshop also provided some valuable lessons for the
  future.

        There is a strong appetite for knowledge and discussion around TB/HIV
        among people from communities facing serious coinfection epidemics.
        The Montreal workshop succeeded in bringing together local community
        leaders from the developing world who were ready and able to use the




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        workshop and conference experience to expand their activities in their
        countries and begin to develop country, regional, and global networks
        addressing TB/HIV coinfection.
        We were not able to bring everyone we invited due to visa and health
        problems, issues that will require consideration for future workshop planning.
        There is a strong desire and need for future meetings and regional workshop.
        Participants indicated a need to identify funding sources to support their
        follow-up education and community mobilization activities.

  TB/HIV Coinfection Education & Community Mobilization Workshop
  Centre St-Pierre Apôtre—1212 rue Panet
  Montreal, Québec, Canada

  Workshop Agenda

        5 October 2002
        Introductions & workshop overview
        TB/HIV overview
        TB/HIV epidemiology, natural history, prevention & treatment—Kenneth
        Castro, CDC
        HIV natural history & treatment—Mark Harrington, TAG
        Access to care & program models—DOTS, ProTEST, etc.—Dermot Maher,
        STB, WHO
        Community mobilization panel discussion
        SANASO, Southern Africa—Farai Mugweni
        Grupo Pela VIDDA, Brazil—Ezio Santos Filho
        EATG Southern/Eastern States—Rob Camp
        Strategies for Community Mobilization (Small Group Discussions and Report
        Back)
        Community Mobilization Overview—Kraig Klaudt, Massive Effort
        Wrap-up & plan for conference activities
        Conference Activities
        6 October 2002
        3rd DOTS Expansion Working Group public meeting
        7-9 October 2002
        33rd International Union Against Tuberculosis & Lung Diseases (IUATLD)
        conference

  TAG TB/HIV Coinfection Education & Community Mobilization Workshop
  Participant List
  David Barr*, AIDS Treatment Activist Coalition (ATAC), USA
  Leopold Buhendwa, Médecins sans FrontiPres-Luxembourg (MSF-L)/Thyolo,
  Malawi
  Rob Camp*, European AIDS Treatment Group (EATG), Spain
  Kenneth Castro*, Centers for Disease Control and Prevention (CDC), USA
  Dagmar Forland, Norwegian Heart & Lung Association, Norway
  Marie-Claude Fournier, Direction de la santé-publique, Canada
  Patrick Gomani, Médecins sans FrontiPres-Luxembourg (MSF-L), Malawi




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  Mark Harrington*, Treatment Action Group (TAG), USA
  Olav Kasland, Norwegian Heart & Lung Association, Norway
  Andrej Kastelic, International Harm Reduction Development—Open Society
  Institute, Slovenia
  Kraig Klaudt*, Massive Effort, Switzerland
  Dermot Maher*, STOP TB, World Health Organization (WHO), Switzerland
  James Mafusire, Botswana Network of PLWHAs (BONEPWA), Botswana
  Pedzisani Motlhabane, Botswana Network of ASOs (BONASO), Botswana
  Farai Mugweni*, Southern African Network of ASOs (SANASO), Zimbabwe
  Ketty Mfune Mumba, Lusaka Home Based Care, Zambia
  Amos Nota, Zambia AIDS Related TB Project, Zambia
  Leonora Omala, INTERSOS, Kenya
  Dorothy Onyango, Women Fighting AIDS in Kenya (WOFAK), Kenya
  Ludfine Opudo, Society of Women Against AIDS—Kenya (SWAK), Kenya
  Manoj Pardesi, Network of Maharashtra PLWHAs, India
  Daniel Raymond*, TAG, USA—Workshop Coordinator
  Kirsten Rrhme, Norwegian Heart & Lung Association, Norway
  Ezio Santos-Filho*, Grupo Pela VIDDA-Rio de Janeiro/TB Control Program/RJ-
  MSH, Brazil
  Gaseone Serite, Botswana Network of PLWHAs (BONEPWA), Botswana
  Peter Small, Gates Foundation, USA
  David Thompson, Canadian HIV/AIDS Legal Network, Canada
  Svain Wasshaug, Norwegian Heart & Lung Association, Norway
  Winstone Zulu*, Network of PWHIV, Zambia
  * Denotes presenter/moderator


  TB/HIV Education & Community Mobilization Workshop
  Steering Committee
  Nils Billo, M.D., IUATLD
  Joanne Carter, Results
  Kenneth Castro, M.D., CDC
  Ben Cheng, Forum for Collaborative HIV Research
  David Cohn, M.D., UCHSC & Denver DOH
  Fred Gordin, M.D., VA Medical Center, Washington, D.C.
  Robert Eisinger, Ph.D., Office of AIDS Research, NIH
  Mark Harrington, TAG
  Petra Heitkampp, STOP TB, WHO
  Alan Hinman, M.D., The Task Force for Child Survival and Development
  Vivien Jackson, World Bank
  Barbara Laughon, Ph.D., Division of AIDS, NIAID, NIH
  Dermot Maher, M.D., STOP TB, WHO
  Michael Marco, Social & Scientific Systems
  Bess Miller, M.D., CDC
  Scott McCoy, CDC
  Ferai Mugweni, SANASO, Zimbabwe
  William Pick, J.D., USAID
  Daniel Raymond, TAG—Workshop Coordinator
  Lee Reichman, M.D., UMDNJ—Medical Faculty Leader
  Joëlle Tanguy, Global Alliance for TB Drug Development




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    TB/HIV Project vIndex

   TAG index
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