Expanded Response to Tuberculosis: What USAID Will Do

b) Scale up Management of MDR-TB and XDR-TB

MDR-TB and extensively drug resistant TB (XDR-TB) compromise TB control efforts and threatens years of progress in controlling TB. Resistance is the result of weak TB programs, poor patient adherence to treatment regimens, and irregularly supplied and/or poor quality drugs. The most recent Anti-Tuberculosis Drug Resistance Surveillance in the World report (2007) identified MDR-TB in all regions of the world, with exceptionally high prevalence in Eastern Europe. WHO estimates that the prevalence of MDR-TB may be as high as one million cases, with approximately 490,000 new cases annually; of these cases, less than 2 percent are treated in accordance with WHO guidelines. In addition, CDC reported the presence of XDR-TB in all regions of the globe, with the highest rates in Eastern Europe. In June 2007, WHO identified 25 priority countries based on estimated MDR-TB and XDR-TB burden.

MDR/XDR-TB is a serious concern because drug-resistant TB is more difficult and expensive to diagnose and cure, contributing to continued disease transmission and higher death rates. Diagnosis of MDR-TB requires laboratory capacity to perform culture and drug sensitivity testing. Second line drugs used to treat MDR-TB are often toxic and poorly tolerated by patients. The duration of treatment is longer than for drug susceptible TB and the cost of treating MDR-TB is 10 to 100 times greater than the cost of treating drug-susceptible TB, which has implications for both health budgets and patient access to care. While cure rates as high as 50-60 percent among MDR-TB cases are possible, successful outcomes depend greatly on good quality TB control programs. MDR-TB and XDR-TB in sub-Saharan Africa is particularly concerning because of the high HIV prevalence, and the rapid progression from TB infection to disease among people with HIV/AIDS. Weak or non-existent infection control measures, combined with congested health facilities, can create an explosive situation for nosocomial transmission of the disease.

USAID has supported activities to address MDR-TB since the inception of its TB program in 1998. USAID’s strategic priorities to address MDR-TB and XDR-TB are fully consistent with WHO’s Global MDR-TB and XDR-TB Response Plan 2007. Seventeen of the 25 priority countries for MDR-TB defined by WHO are among USAID priority countries. USAID supports both the full integration of the diagnosis and treatment of MDR-TB into DOTS programs and measures to improve the quality of services to prevent further emergence of resistance. USAID supports country-level drug resistance surveys and the biannual Global Report on TB Drug Resistance. USAID has supported the Green Light Committee (GLC) since it was established. The Agency’s assistance enables the GLC to provide technical assistance to GLC applicants and GFATM grant recipients. Attention is given to capacity building for management of second-line anti-TB drugs and to improving good manufacturing practices of second line drug manufacturers to help expand the supply of quality assured second line drugs. In addition, USAID supports the expansion and strengthening of laboratory services through activities such as establishing supranational reference laboratories and fostering partnerships with regional Centers for Excellence. Finally, USAID supports technical assistance, interventions and capacity building to improve infection control and research to improve approaches for monitoring and managing drug resistant TB.