Expanded Response to Tuberculosis: What USAID Will Do

d) Adapt DOTS to address special challenges

HIV/AIDS and MDR TB present special challenges to the expansion and effectiveness of DOTS programs. USAID’s response to each of these challenges is described below.

HIV/AIDS and TB co-infection: Currently, about 42 million people are HIV-infected and almost one-third are also infected with TB. The dual epidemics of TB and HIV are particularly pervasive in Africa, where HIV has been the single most important factor contributing to the increasing incidence of TB over the last ten years; currently in many African countries more than 50 percent of patients with active TB disease are also HIV-positive. The dual epidemics are also of growing concern in Asia, where two-thirds of TB-infected people live and where TB now accounts for 40 percent of AIDS deaths. Eastern Europe and the Former Soviet Union have the fastest growing HIV epidemic in the world, and could particularly exacerbate problems with the MDR TB epidemic in the region of Eastern Europe and the former Soviet Union.

Persons infected with both HIV and TB are 30 times more likely to progress to active TB disease. Recent studies have shown that infection with TB enhances replication of HIV and may accelerate the progression of HIV infection to AIDS. Fortunately, TB treatment for HIV-positive patients under DOTS is just as effective as it is for people who are HIV-negative. In addition, clinical trials have shown that prophylaxis using anti-TB drugs can prevent or decrease the likelihood of TB infection from progressing to active TB disease in an HIV-infected person, making it an important intervention for increasing the length and quality of life of HIV-infected people, with benefits to their families and communities.

The objectives of USAID assistance in this area are to actively improve the coordination and harmonization of TB and HIV/AIDS interventions and programs to increase access to TB services (including TB screening and prophylaxis) for people infected with HIV, and increase access to HIV testing and other services for people infected with TB.¹ In addition, USAID will increase the knowledge base, quality and availability of information on TB/HIV co-infections.

To achieve these objectives USAID will focus on three key interventions. Improved coordination of TB and HIV services is essential to ensure early diagnosis, appropriate referral, and prompt, quality care for each disease. To accomplish this, USAID will: support coordination and collaboration between HIV and TB national programs; strengthen and link TB services to VCT and HIV care services; develop training programs on for TB specialists/programs managers on VCT and management of co-infected patients for all levels of providers, as well as TB training modules for VCT providers; and improve coordination among host countries and donor agencies, NGOs, and research institutions. USAID will also explore the use of alternative service delivery approaches, such as community and home-based care, and the involvement of faith-based organizations in such approaches.

USAID will also support improvements in TB service delivery system links with anti-retroviral (ARV) treatment services. Facilities that provide HAART (highly active anti-retroviral therapy) for co-infected patients offer a critical opportunity for TB-HIV/AIDS collaboration. Given the need to modify or delay the TB treatment for individual patients who are receiving HAART, care of these patients must be coordinated. Furthermore, the HIV/AIDS community is eager to take advantage of the lessons learned from DOTS program experience, including the application of DOTS principles to treatment programs. USAID will support pilot service delivery models for reaching co-infected patients, monitor and analyze the effectiveness of such models, and document these experiences.²

Finally, USAID will strengthen and expand TB and HIV surveillance to improve the detection of TB/HIV co-infection and the quality of data on co-infection and epidemiological trends.

MDR TB: Proper treatment of susceptible strains of TB requires multiple drugs over six to eight month period. If therapy is irregular or the drugs are of poor quality, resistant TB strains become dominant. In the 22 HBCs that have completed national or sub-national TB drug resistance studies, rates of MDR TB range from 0 - 10 percent³ in infectious cases that have not been previously treated; levels are generally higher in previously treated cases. Even in non-high burden countries, high MDR rates pose serious threats to the local population. This situation is a concern because drug-resistant TB is more difficult to cure, which translates into greater disease transmission and higher death rates. Second line drugs used to treat MDR TB are often toxic and disabling to patients. The cost of treating MDR TB ranges from 10 to 100 times greater than it is for drug-susceptible TB, which has implications for both health budgets and patient access to care.

USAID will support a two-fold approach to address MDR TB. USAID will support the strengthening of DOTS programs to improve adherence to recommended treatment regimens and to prevent the emergence of MDR TB. USAID Assistance will be provided to improve procurement and management of high-quality drugs, and strengthen routine monitoring of drug quality. In addition, USAID will support interventions to improve the treatment of MDR TB. Attention will be given to better monitoring and recording of treatment failures, implementing studies to measure TB drug resistance, expanding laboratory capacity to monitor drug-resistance, introducing new drugs and/or treatment regimens, and support for operations research (such as DOTS Plus for MDR TB pilot projects) to reduce poor outcomes. Expanding the involvement of the private sector in DOTS will be addressed as well, since TB treatment by private health providers is often inconsistent with the recommended drug regimens (e.g. type of drug, dose, and duration) and drug quality standards.

USAID will also support training of private sector providers to raise their awareness of DOTS, as well as programs that link private sector providers with the national TB program. Finally, USAID will support development of a tracking tool to assist the Green Light Committee (GLC)⁴ in scheduling shipments, monitoring drug inventory, and identifying technical support required for the GLC to carry out its expanded role as the procurement and distribution mechanism for GFATM grants awards involving second line TB drugs.

¹USAID’s HIV/AIDS programs will be principally responsible for funding of HIV testing and other services.

²USAID will support these activities through combined funding from the HIV/AIDS and TB programs.

³““Anti-Tuberculosis Drug Resistance in the World.” Report No. 2 Prevalence and Trends, The WHO/IUATLD Global Project on Anti-Tuberculosis Drug Resistance Surveillance, Communicable Diseases, WHO, 2000.

⁴The GLC is a technical review committee that functions under the auspices of the STOP TB Partnership) that reviews and guides DOTS Plus for MDR TB pilot projects. Pilot projects that receive GLC approval are eligible to purchase second-line anti-TB drugs through a GLC pooled procurement mechanism.