East Africa

The USAID/East Africa regional Mission focuses on seven countries, five of which are high-burden tuberculosis (TB) countries (Democratic Republic of the Congo, Ethiopia, Kenya, Uganda, and Tanzania). USAID/East Africa also has a mandate to provide technical assistance to USAID limited-presence countries (Burundi, Comoros, Djibouti and Somalia). Sudan receives TB funds because the country is rebuilding services after 30 years of war. Djibouti also receives limited TB funding due to its key role in the U.S. Government war on terrorism. The seven focus countries accounted for 11 percent of the global TB burden in 2006. DOTS (directly observed treatment, short course) case detection rates in the five TB priority countries range from a low of 27 percent in Ethiopia to a high of 70 percent in Kenya, the only African country in East and Central Africa meeting the World Health Organization’s (WHO’s) global target.

Efforts to assess improvements in case detection in the Africa Region have been confounded by the increased number of people testing for HIV/AIDS and TB and by lack of access to TB smear microscopy centers. For example, in Kenya, when sputum smear positive notifications increased from 92 to 107 per 100,000 between 2000 and 2006, this was mostly due to an increase in case detection rather than an increase in TB incidence linked to HIV. At the same time, the low case detection rates in Djibouti, Ethiopia, and Sudan are due to lack of access to laboratory diagnostic services. The USAID/East Africa subregion has both high HIV prevalence (adult HIV prevalence rate equal to or greater than 4 percent) and low HIV prevalence subregions, and works to implement appropriate strategies in these different contexts. In the TB priority countries with high TB-HIV/AIDS co-infection rates, considerable focus has been placed on strengthening TB-HIV/AIDS interventions (e.g., offering HIV CT and cotrimoxazole preventive treatment to clients in TB programs and screening HIV-positive patients for TB signs and symptoms, providing TB treatment to those with active disease and isoniazid preventive treatment to those with latent TB, and improving infection control in congregate settings).

Key issues in the region include a lack of focus on delivering high-quality DOTS, which has increased the spread of MDR-TB. Laboratory infrastructure remains weak throughout the region; currently on the African continent only South Africa has the capacity to diagnose multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB. MDR-TB had initially not been a problem for East and Central Africa, but as national TB programs change their drug regimen to include rifampicin in both the intensive and continuation phases, MDR-TB rates have been rising and countries are faced with the need to both access second-line drugs and conduct MDR-TB surveys to assess the true extent of the problem.

USAID Approach and Key Activities

USAID/East Africa’s regional program has a mandate to build the capacity of African regional institutions, and has sought African partners to improve, expand, and enhance DOTS programs since 2002. Recognizing the need for improving the quality of DOTS provision, USAID is working with the Regional Centre for Quality of Health Care (RCQHC) to strengthen health workers’ skills and capacity. USAID/East Africa provides technical assistance to support countries in implementing the current WHO strategy to improve community-based DOTS (C-DOTS) to prevent and control TB, increase public-private partnerships, and fully scale up TB-HIV/AIDS collaborative activities. In addition, regional funds support RCQHC to work on pediatric TB, which has not received the focus it deserves. Future activities will focus on establishing a Center of Excellence for MDR-TB to provide health staff of countries with a high burden of MDR-TB an opportunity to study and implement DOTS for MDR-TB. USAID assistance includes the following:

• Leading efforts to put the re-emerging threat of TB on the forefront of the agenda of African Ministries of Health and supporting Ministers to scale up interventions to better manage TB-HIV/AIDS
• Improving the quality of DOTS by training personnel to ensure that patients are on appropriate drugs and are adhering to the full TB regimen
• Providing technical assistance to countries to upgrade and fully expand functional external quality assurance systems for TB laboratory services
• Advocating at the national and international levels for higher and sustained political commitment to TB control
• Developing standard operating procedures for National Tuberculosis Reference Laboratories and strengthening their capacity to further the development of a Supranational Reference Laboratory in the East Africa region
• Providing technical assistance to improve existing laboratory techniques and introducing new techniques, including fluorescence microscopy, liquid culture, and drug sensitivity testing (DST) and DST of second- line drugs
• Increasing information and awareness of pediatric TB among TB program managers in order to develop a more focused response to increasing cases of pediatric TB-HIV/AIDS co-infections
• Building capacity of the RCQHC to provide training on MDR-TB and to conduct operational research
• Establishing “collaboratives” to link TB staff from different countries in a network to improve TB control and treatment
• Expanding C-DOTS to bring TB services and increased awareness of TB to the community level

USAID Program Achievements

• Trained 255 participants in DOTS expansion, case management of MDR-TB, and the integration of TB into focused antenatal care (ANC) clinics in Kenya, Uganda, Ethiopia in fiscal year 2007, exceeding the TB training target by 78 percent
• Developed guidelines on how to measure the quality of TB services from the patient’s perspective and how to integrate TB into focused ANC clinics
• Developed guidelines and introduced new programmatic approaches addressing pediatric TB and developed standard operating procedures for National Tuberculosis Reference Laboratories
• Supported drug resistance surveys in the Democratic Republic of the Congo
• Supported Ethiopia in the development of a grant from the Green Light Committee for MDR-TB treatment

Partnerships

Forming partnerships has been one of the most important elements in combating TB the Region. USAID implements the Tuberculosis Control Assistance Program through the KNCV Tuberculosis Foundation. In addition to USAID, international collaborators that have invested in efforts to improve TB control include the WHO, KNCV Tuberculosis Foundation, International Union Against Tuberculosis and Lung Disease, Management Sciences for Health, and RCQHC. The Global Fund to Fight AIDS, Tuberculosis and Malaria is one of the major donors to national TB programs in East and Central Africa. Global Fund resources from Round 6 are programmed to support the National Tuberculosis Reference Laboratory and the laboratory network system in Uganda and Tanzania. The Foundation for Innovative New Diagnostics is also operating in the above countries and Ethiopia.

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January 2009

Related Links

• USAID Overview of East Africa