Expanded Response to Tuberculosis: What USAID Will Do

a) DOTS Expansion and Enhancement

DOTS is a cost-effective and affordable strategy for controlling TB, and consists of five components: political commitment with increased and sustained funding; case detection through quality-assured bacteriology; standardized treatment, with supervision and patient support; an effective drug supply and management system; and a monitoring and evaluation system, including impact measurement. Good quality DOTS also slows the emergence and spread of drug-resistant TB. DOTS can be adapted to a variety of different settings and local conditions, and the regimens used are also effective in curing TB in people who are co-infected with HIV.

USAID supports interventions to increase access to and the quality of DOTS in priority countries to achieve international targets for case detection (70 percent of new smear-positive cases detected) and treatment (85 percent of new sputum smear-positive pulmonary TB cases successfully treated). More specifically, USAID works with host countries in developing strategic plans and budgets that are consistent with the Stop TB Strategy and Global Plan. Investments are directed towards promulgating standardized treatment with context specific and patient-oriented supervision; improving TB program management and supervision; personnel training; effective procurement and management of a dependable supply of high-quality TB drugs; expansion and strengthening of high-quality laboratory services, including culture capacity; and routine monitoring of treatment outcomes and overall program performance. USAID also provides technical assistance to prepare proposals to the Global Fund to Fight AIDS TB and Malaria (GFATM) and assist in successful implementation of the GFATM grants and provides funding to the Global TB Drug Facility (GDF) for grants for TB drugs to countries in need.

To complement DOTS expansion efforts through national TB programs, USAID supports initiatives to engage all health care providers through public-public and public-private mix (PPM) approaches. Many people initially seek treatment in the private sector. Partnerships with these private and NGO providers help to increase equity, reduce diagnostic delay and to extend the reach of TB services to populations that may have difficulty accessing public sector services. USAID Missions work in consultation with National Tuberculosis Programs and other stakeholders to determine how to best maximize the reach of services given each country’s context. Integration of the International Standards of TB Care (ISTC) into PPM activities serves to ensure that PPM activities are consistent with global standards of care. ISTC also serves as a tool to engage professional associations.

DOTS programs with the goal of achieving better treatment outcomes, reducing diagnostic delay, preventing disease transmission, and slowing the emergence of MDR-TB5. Although the case detection rate for new sputum smear-positive cases is 61 percent among DOTS programs in the 22 HBCs, only eight HBCs reached the target of 70 percent. Case detection was lowest in the African (46 percent), European (52 percent), and Eastern Mediterranean (52 percent) regions. Furthermore, while overall treatment success under DOTS averaged 84.7 percent, only ten of the 22 HBCs met or surpassed the 85 percent target. Unfavorable outcomes (defined as death, treatment failure, and default) were unacceptably high in Europe (24.4 percent) and Africa (16.9 percent). Attention is given to ensuring that all those suspected of having TB are correctly diagnosed, that diagnosed patients begin therapy, that clinicians and nurses adhere to program norms or standards, that patients are supported to adhere to treatment regimens, and that outcomes are documented and reported. Training is provided in the correct use of TB registries and in monitoring and evaluation systems to improve data quality, and to enhance the ability of local personnel to analyze and use their data to improve program performance.

USAID continues to support WHO Global TB Monitoring and Surveillance project as a key investment in providing information on the global, regional, and country level TB program and epidemiological situation. The Agency provides technical and financial support for TB prevalence surveys and plays a key role in the standardization of monitoring and evaluation instruments. Existing tools are evaluated and adapted and new tools are developed to assist USAID missions and TB program managers in the use of effective benchmarks for measuring progress and evaluating TB activities throughout the lifecycle of their programs.

Finally, USAID supports partnerships that empower people with TB and communities including advocacy, communication, and social mobilization (ACSM). Community participation in TB care is encouraged via implementation of community-based treatment support approaches and advocacy to increase local and national support and resources for TB control. Information, education, and communication (IEC) activities are supported to reduce stigma, raise awareness, increase demand for services, and promote adherence to treatment. USAID also supports advocacy for implementation of the Patients’ Charter for Tuberculosis care to enable patients and communities to raise awareness about the rights of people with TB and to strengthen patient-provider relationships.