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Pediatric TB and HIV The Potential of New TB Vaccines Dr. Hoosen Coovadia Nelson Mandela School of Medicine, University of KwaZulu Natal Board of Directors, Aeras Global TB Vaccine Foundation Presentation to the CORE Group May 17, 2010

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Estimated TB Incidence Rate, 2007

Estimated new TB cases (all forms) per 100 000 population No estimate 0-24 25-49 50-99 100-299 >= 300

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2009. All rights reserved

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HIV Prevalence Among TB Cases, 2007 Global estimate: about 1.4 million TB/HIV cases and 450,000 TB/HIV deaths a year

HIV prevalence in TB cases, (%) No estimate 0–4 5–19 20–49 >= 50

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2009. All rights reserved

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HIV/AIDS and TB: A Deadly Combination

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One in four HIV deaths is linked to TB

HIV suppresses the human immune system TB suppresses the human immune system Each makes the other worse synergistically The number of new cases of TB has more than doubled in countries with high HIV prevalence in the past 15 years

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Drug Resistance • WHO estimates 490,000 MDR-TB cases emerge every year, with more than 110,000 deaths • Extensively drug-resistant (XDR) TB has been identified in 57 countries as of November 2009 • In 2008, WHO reported that the highest rates of MDR TB ever recorded, with peaks of up to 22% of new TB cases, were in some settings of the former Soviet Union. In the same region, 1 in 10 cases of MDR-TB is XDR-TB • Treatment for drug-resistant TB is much longer, more complex and more expensive - with much lower success rates

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Global Health issues for children

WHO, “World Health Statistics, 2010”

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Human Rights Issue • No vaccine to provide long-term protection from pulmonary TB • No HIV vaccine • No benefit from biomedical advances for people and communities affected by TB • TB exposure due to inadequate health systems – poor delivery of INH prophylaxis • TB and HIV diagnostics inadequate for testing children • Poor pediatric tracking programs to measure incidence • Social circumstances lead to exposure – poverty, malnutrition

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Pediatric HIV • 2.1 million children were living with HIV/AIDS, vast majority in sub-Saharan Africa. • 1000 children get newly infected with HIV each day. • Children acquire HIV from their HIV-infected mothers during pregnancy, birth or breastfeeding.

• PMTCT works, but needs broader rollout and accessibility to those who need it most.

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Maternal TB/HIV important risk factor for pediatric TB and mortality • Estimated TB rate: -10 times higher in HIV-exposed uninfected children