BATTLE AGAINST HIV/AIDS, MALARIA & TB ARE WE WINNING?

BY SHAARI NGADIMAN,
MD, MPH, EIP, AM

MINISTRY OF HEALTH MALAYSIA

drshaari@moh.gov.my

HIV/AIDS kill > 20 millions 90% Malaria death in Africa TB death about 1.8 millions TB/HIV death about 0.5 million

Evolution of the Millennium Development Goals

World leaders at the United Nations Millennium Summit held in New York in September 2000 resolved to strengthen global efforts for peace, democracy, good governance, and poverty eradication while continuing to promote the principles of human rights and human dignity. The Millennium Declaration made a strong commitment to the right to development, to gender equality and the empowerment of women, to the eradication of the many dimensions of poverty, and to sustainable human development. The Millennium Development Goals (MDGs) emerged as the principal means of implementing the Declaration.

Evolution of the Millennium Development Goals

In September 2000, 189 world leaders including Malaysia adopted the Millennium Declaration which was translated into a set of eight Millennium Development Goals The goals have been commonly accepted as framework for measuring development progress. In September 2005, the UN Summit resoundingly endorsed these MDGs. These goals are set for the target year of 2015 with 1990 as the baseline and are summarized on issues that afflict developing countries like ours.

Millennium Development Goals 8 goals

MDG 1 - to eradicate extreme poverty and hunger. MDG 2 - to ensure all boys and girls complete a full course of primary schooling, in other words universal primary education. MDG 3 - relates to the status of women, by promoting gender equality and empowerment of women. MDG 4 - to reduce child mortality.

MDG 5 - to improve maternal health.

MDG 6 - to combat HIV/AIDS, malaria and other diseases. MDG 7 - to ensure environmental sustainability, and the measures relate to safe drinking water and slum dwellers. MDG 8 - to develop a global partnership for development. Many of these relate to trade and financing systems that will benefit countries those saddled with debts.

TARGETS AND INDICATORS

MDG 6a Target Have halted by 2015 and begun to reverse the spread of HIV/AIDS Indicators 6b Achieve universal access to treatment for HIV/AIDS for all who need it by 2010 Have halted and begun to reverse the incidence of malaria and other major diseases by 2015 Prevalence among 15 24 years Condom use at last high risk sex Proportion with comprehensive correct knowledge Ratio of school attendance of orphans Proportion of infected persons (advanced HIV) with access to ART

6c

Incidence and death rates Insecticide-treated bed nets Appropriate anti-malarial drugs (fever) TB incidence, prevalence and death rates Detection and cure rates (DOTS)

BATTLE AGAINST HIV/AIDS, MALARIA & TB ARE WE WINNING?

PART 1 HIV / AIDS

SYNOPSIS GLOBAL SITUATION

SYNOPSIS GLOBAL SITUATION

SYNOPSIS GLOBAL SITUATION

SYNOPSIS GLOBAL SITUATION

Target of NSP on AIDS 2011-15

80% MARPs reached prevention programmes 60% of MARPs use condoms consistently. 60% of IDUs use clean injecting equipment. Able to eliminate vertical HIV transmission 80% ARV coverage for eligible PLHIV,

HIV NOTIFICATION IN MALAYSIA

Annual Notification of HIV/AIDS and HIV&AIDS Death , Malaysia 1986 - 2012
Cumulative HIV = 98,279 Cumulative deaths = 15,688 PLHIV (end of 2012) = 82,591

No. of Annual HIV Testing and Positive Rate

1,500,000

No. screening

Detection Rate
1.5

No. screening

1,000,000

1
500,000

0.5

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year

Detection rate (%)

NEW HIV CASE: TARGET FOR 2015

YEAR

2008
TARGET ACHIEVED 16.0 13.3

2009
15.3 10.8

2010
14.6 12.8

2011
13.9 12.2

2012
13.2 11.7

2013
12.5

2014
11.7

2015
11.0

Target : To reduce new HIV from 21.7 per 100.000 pop (year 2000) to 11 per 100,000 pop by year 2015

TB-HIV CO-INFECTION IN MALAYSIA

Isoniazid Prophylaxis Therapy in 2010

MALAYSIA HIV SITUATION

100 90
80

Percentage of HIV cases

70 60
50

40 30
20

10 0 1990 1992 1994 1996 1998 2000 IDU 2002 Sexual 2004 2006 2008 2010 2012

MALAYSIA HIV SITUATION

Estimated Prevalence of Selected Groups EPP Model 2013

COVERED (2012):
PROGRAMME: (REGISTERED CLIENTS) NSEP (55,255) MMT (27,756) Retention Rate 70.1 (2012) PRIVATE GPs DST (22,000) Estimated PWID : 170,000 Coverage about : 62%

CUMMULATIVE ON HAART AS 31 DEC 2012

39,000 Adult Eligible for ARV in 2012 (EPP Model) 39,000 Adult Eligible for ARV in 2012 (EPP Model)

15,028 on ARV in 2012

Expenditure 2008 2012

60000000
Expenditure (USD)
DOMESTIC FUND FOR HIV WORKS

50000000 40000000 30000000 20000000 10000000 0 2008 2009 2010 2011 2012
ARV : 2011 USD 16.10 mil 2012 USD 20.41 mil
USD 16.76 Line ARV USD 3.65 2nd Line ARV 1st

38%

Global Fund Domestic

BATTLE AGAINST HIV/AIDS ARE WE WINNING?

YES , WE ARE ON TRACK!

BATTLE AGAINST HIV/AIDS, MALARIA & TB ARE WE WINNING?

PART 2 MALARIA

6c: HAVE HALTED AND BEGUN TO REVERSE THE INCIDENCE OF MALARIA AND OTHER MAJOR DISEASES BY 2015
MALARIA
Have achieved target of halting and reversing the incidence of malaria

Can we really win the fight against malaria?

In the past ten years, increased investment in malaria prevention and control has saved more than a million lives,

This is a tremendous achievement. But we are still far from achieving universal access to life-saving malaria interventions.
Until countries are able to test, treat, and report every malaria case, we will never defeat this disease, "We need strong and sustained political commitment from all countries where malaria is endemic, and from the global health community, to see this fight through to the end. Dr Margaret Chan, WHO Director-General.

GLOBAL MALARIA
Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected mosquitoes. In 2010, there were about 219 million cases of malaria and an estimated 660 000 deaths globally. Approximately half of the world's population is at risk of malaria. Most malaria cases and deaths occur in subSaharan Africa. In 2011, 99 countries and territories had ongoing malaria transmission.

MALARIA IN MALAYSIA
300,000 243,870

250,000

In 1961, there were 243,870 malaria cases reported in Malaysia while in 1990, the cases have declined to 50,500.
181,495

151,822

200,000

A decade later, in the year 2000, the number of reported cases have further decreased to 12,705 cases.
In 2012, there were 4,725 cases which is a 63% reduction compared to 2000.
69,127 55,068 50,500 58,958 59,208 49,526 44,226 48,007 41,708 39,189 51,921

150,000 87,432

100,000

36,853

39,890

13,491

11,106

12,705

12,780

11,019

50,000

26,649

7,390

7,010

6,338

6,154

5,569

5,456

6,650

5,306

5,294

1961 1967 1980 2011

Malaria Eradication Programme (Sabah & Sarawak) Malaria Eradication Programme (Peninsular Malaysia) Malaria Control Programme National Strategic Plan for Elimination of Malaria (2011-2020)

4,725

6c: HAVE HALTED AND BEGUN TO REVERSE THE INCIDENCE OF MALARIA AND OTHER MAJOR DISEASES BY 2015
MALARIA
Have achieved target of halting and reversing the incidence of malaria

Malaysia has achieved the MDG goal for malaria well ahead of the 2015 deadline and has built on these achievements to strengthen current efforts and secure further commitments towards elimination by 2020 which is the target for Malaysias MDG-Plus. The incidence of malaria has declined from 289.5 per 100,000 populations in 1990 to 54.6 per 100,000 populations by year 2000 and to 16.4 per 100,000 populations in 2012. (Target to reduce to 27.3 per 100,000 by 2015 but achieved much earlier) There has also been a reduction in the number of malaria deaths from 43 in 1990 to 35 in 2000 and to 16 deaths in 2012. The mortality rate due to malaria has been around 0.1 per 100,000 population since 2006.

MALAYSIA: NSP MALARIA, MALARIA ELIMINATION 2011 - 2020

GENERAL OBJECTIVE
o

To ensure Malaysia is free from local malaria transmission by 2020 Peninsular Malaysia malaria free by 2015 Sabah & Sarawak malaria free by 2017
2011 - 2015 2011 - 2017

SPECIFIC OBJECTIVES
o o

STRATEGY 1. Early case detection & prompt treatment 2. Close monitoring of imported cases 3. Residual spraying 4. Usage of bednets 5. Environmental management & anti larva. 6. Monitoring of drug resistance 7.Collaboration with the neighbouring countries

CHALLENGES
Malaria transmission in Sabah and Sarawak.

Malaria transmission among migrant workers.

Ensuring effective and efficient malaria prevention and control measures. Inaccessible remote areas especially in Sabah and Sarawak Zoonotic infection (Plasmodium knowlesi) Control activities at the border areas

BATTLE AGAINST MALARIA ARE WE WINNING?

YES , WE ALREADY WIN THE GAME!

BATTLE AGAINST HIV/AIDS, MALARIA & TB ARE WE WINNING?

PART 3 TUBERCULOSIS

MANAGING TB SITUATION IN MALAYSIA

The National Tuberculosis Control Programme (NTBCP) in Malaysia was launched in 1961 as a vertical programme with the main aim to control and reduce the prevalence of tuberculosis as a public health concern. BCG Vaccination program was introduced as one of the strategies of NTBCP in the same year. In 1995, the programme was integrated into the general medical and health system following WHOs recommendation and implementation of primary care concept in Malaysia. Ministry of Health is the leading agency in NTBCP and collaborates with other ministries and relevant non governmental agency for this course. Malaysia is classified as a country with an intermediate TB burden, that is, with an incidence of between 20-100 reported cases per 100,000 population annually. Since the implementation of national TB Control Program in 1961, the number of reported TB cases had successfully reduced to from 350 cases per 100,00 to less than 100 per 100,000 in 1980s. However, since then reported TB cases has remained unchanged between 60 to 68 per 100,000 population. It was noted that the reported TB cases had show slight increment since 2004.

Thailand Cambodia Viet Nam Philippines

Myanmar

Sabah

Pinang

KL

Johor

Sarawak

Indonesia
Indonesia

Tuberculosis in the World

Incidence: 9.5 million new cases/year Prevalence: 14 million cases 95% of cases in resource poor settings 1.1 millions co-infection TB/ HIV

(12% HIV Positive have TB)

1.7 millions deaths/year 98% deaths in poor resource countries

WHO 2010

Incidence Rate and Mortality Rate Of Communicable Disease 2012 (per 100,000 population)
Communicable Disease Food and Water Borne Disease Cholera Dysentry Food Poisoning Typhoid Hepatitis A Vector Borne Disease Dengue Dengue Haemorrhagic Fever Malaria Typhus Plague Yellow Fever Vaccine Preventable Disease Acute Poliomyelitis Diphtheria Measles Other Tetanus Neonatal Tetanus Hepatitis B Whooping Cough Sexually Transmitted Disease Chancroid Gonorrhoea Syphilis Other Infectious Disease HIV AIDS Ebola Hepatitis C Hand, Foot & Mouth Diseases Leprosy Other Specified Viral Hepatitis Rabies Relapsing Fever Tuberculosis Viral Encephalitis H1N1 Leptospirosis Influenza Source: Disease Control division, MOH Incidence Rate 0.96 0.29 44.93 0.75 1.58 72.20 2.45 16.11 0.03 0.00 0.00 0.00 0.00 6.39 0.08 0.02 8.99 0.76 0.00 5.09 5.70 11.72 4.64 0.00 5.91 117.67 1.10 0.26 0.00 0.00 77.41 0.08 0.93 12.49 2.90 Mortality Rate 0.003 0.000 0.003 0.003 0.000 0.000 0.119 0.050 0.000 0.000 0.000 0.000 0.000 0.000 0.010 0.004 0.070 0.010 0.000 0.000 0.003 0.570 1.820 0.000 0.109 0.003 0.000 0.000 0.000 0.000 4.900 0.006 0.010 0.164 0.024

18 304 new TB cases (mean ~ 50 cases /day) 1414 TB death (mean ~ 4 death/day)

Source: Disease Control Division, Ministry of Health, 2012

Incidence Rate (Notification Rate) of TB in Malaysia, 1990-2012

Rate/100,000
140 127

120
100 80 60 61 40 20 0 Year 68 95 82 81 77 78

72

65

WHO Estimated Incidence R per 100,000 1990-2020 Malaysia Reported Incidence Rate (Notification Rate) per 100,000, 1990-2012

1. Not achieving WHO estimated incidence case 2. WHO Estimation Notification Rate (NR) downwards trend 3. Actual NR increasing (CDR 2011: 85%, 2012 :95%)

Malaysia: TB Mortality Rate, 1990-2012

Rate/100,000
30.0
26.0

25.0 20.0 15.0 10.0 5.0

4.2 4.4 5.6 5.5 5.5 13.0 8.5 8.2 7.9

Year

7.1

5.8

4.9

0.0

2000

2013

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2014

2015

2016

2017

2018

2019

WHO Estimated Mortality Rate (Excluding TBHIV Mortality) per 100,000, 1990-2020 Malaysia Reported TB Mortality per 100,000, 1990-2012
1. 2. 3. 4. WHO estimated mortality rate (MR) is excluding TBHIV mortality Actual MR : 1990-2011 including TBHIV mortality; 2012 excluding TBHIV mortality. WHO estimated MR downward trend Actual MR : plateau since 1990

2020

Year

TB prevalence and mortality, Malaysia

Prevalence
250

Mortality
30

227
Deaths per 100,000 population

26
25

Cases per 100,000 population

200

20

150

107
100

15

8.5 Target = 13

Target = 113

10

50

0 1990 1995 2000 2005 2010 2015

0 1990 1995 2000 2005 2010 2015

Treatment Outcome New Smear Positive Cases, Cohort 2005-2011

%
100

80

60

40

20

2005 12 0

2006 42 0

2007 15 0

2008 9 0

2009 8 0

2010 7 0

2011 8 0

Not evaluated

Failed
Defaulted Died Complete Cure

10
8 1 69

3
6 3 46

5
8 5 67

4
8 1 78

4
9 1 78

4
9 1 79

4
9 1 78

Cure Rate shows improvement . Management of TB patient need to strengthen especially on detection of default cases and on decreasing deaths during TB treatment (TBHIV).

Treatment Outcome New Smear Positive Cases, Cohort 2005-2011

Treatment Outcome New Smear Positive Cases, Cohort 2005-2011
%
100

80

60

40

20

2005 12 0 10 8 1 69

2006 42 0 3 6 3 46

2007 15 0 5 8 5 67

2008 9 0 4 8 1 78

2009 8 0 4 9 1 78

2010 7 0 4 9 1 79

2011 8 0 4 9 1 78

Not evaluated Failed Defaulted Died Complete Cure

Cure Rate shows improvement . Management of TB patient need to strengthen especially on detection of default cases and on decreasing deaths during TB treatment (TBHIV).

Cure Rate States in Malaysia, Cohort 2010,2011 & 2012

Cohort 2011 Cohort 2010 Cohort 2009

Target 85%

MALAYSIA Sarawak

Sabah
WP(Labuan) Kelantan Terengganu Pahang Johor Melaka N.Sembilan WP(KL) Selangor Perak P.Pinang Kedah Perlis 0 15 30 45 60 75

TB control in Malaysia: 1995-2015

Special Project (2000 2010)
Policies Notification of TB under CDC Act 1988 National Tuberculosis Information System (TBIS 2002) Practice Guidelines For The Control And management of TB 2nd edition 2002 BCG Guidelines on TB in Prison Guidelines on TB in Rehabilitation Centre Direct Smear Microscopy 2000

TB Control integrated to Public Health

Intermediate targets 70% Case Detection 85% Treatment success 100% DOTS Coverage

MDG
Impact targets Reverse

1995

2000

2005

2010

2015

MALAYSIA NSP TO CONTROL TB

Malaysia National Strategic Plan 2011-2015

2. Enhancing case detection of TB

3. Delivering, enhancing and expanding highquality TB treatment 4. Empower people with TB and the community

Vision
To reduce the burden of TB
NSP To Control TB 2011-2015 Strategies
1.Strengthening components of health system 5. Limiting people from contracting TB

Goal

To accelerate the reduction of TB related

morbidity and mortality towards the achievement of the TB related MDG targets by 2015.

6. Promote TB centered research

High Risk Groups

TB Burden in General Population : 77 per 100,000

HCW

98
Migrant 127 Elderly 132

*DM 351
Close Contact 708 Prisoner 752 Drug Rehabilitation Inmates 937 HIV positive 1782

*HCW- Health Care Worker *DM-Diabetes Mellitus

6c: HAVE HALTED AND BEGUN TO REVERSE THE INCIDENCE OF MALARIA AND OTHER MAJOR DISEASES BY 2015
TUBERCULOSIS
Have achieved target of halting and reversing the incidence of tuberculosis

Have not achieved target of halting and reversing the incidence of tuberculosis. Unlikely to achieve by 2015
Rate/100,000
140 127

120
100 80 60 40 20 0 61

Estimation by WHO

95 82 81 77 78

Actual Incidence

65

68 72

Year

BATTLE AGAINST TUBERCULOSIS ARE WE WINNING?

NOT YET!, NEED INNOVATIVE AND VIGOROUS APPROACH TO WIN THE GAME!

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