Key Achievements in Tuberculosis: Fiscal Year (FY) 2005
Expanding and Strengthening DOTS
USAID provided support for expanding and strengthening DOTS programs in 37 countries in 2005. Key activities included capacity building, improving monitoring and supervision, laboratory strengthening, increasing access to TB drugs, and improving TB drug management. Effective leveraging of USAID resources with the Global Fund to Fight AIDS, Tuberculosis and Malaria helped gain additional resources for country-level TB control activities. Combined, these activities have produced important results. Highlights include:
- Brazil – USAID worked closely with the Ministry of Health at the national, state, and municipal levels, as well as with the Pan American Health Organization (PAHO), Centers for Disease Control and Prevention (CDC), and the Tuberculosis Coalition for Technical Assistance (TBCTA), to accelerate DOTS expansion. During fiscal year 2005, USAID funded DOTS training for 32,000 health professionals, including laboratory technicians, program managers, physicians, nurses, and outreach workers. As a result of this intensive capacity building, 64 percent of Brazil's 315 priority municipalities are now implementing DOTS, compared with less than 10 percent at the beginning of USAID's program in 2002. The case detection rate (CDR) at the national level increased from 23 percent in 2003 to 53 percent in 2004. USAID provided intensive support to Rio de Janeiro and São Paulo states in particular, where 40 percent of Brazil's TB cases are found. The results in these states have been impressive. On average, 90 percent of cases are receiving DOTS, and the treatment success rate (TSR) is greater than 80 percent in USAID-assisted sites, compared with the national average of 65 percent. USAID also worked very closely with all partners to launch a Stop TB partnership in Brazil and to help prepare an application to the Global Fund that resulted in the approval of a two-year TB grant of $11.6 million.
- Cambodia – Approximately two-thirds of all Cambodians carry the TB bacterium, one of the highest rates in the world. At least 10,000 Cambodians die annually from the disease. USAID's TB focus in Cambodia is to work with communities and build public/private alliances. DOTS therapy for TB has expanded beyond the hospital level and by the end of 2005 was available in all health centers as part of the minimum package of health services. To improve accessibility to DOTS at the community level, especially for the most vulnerable populations, USAID supported expansion of community DOTS to cover more than 40 percent of health centers in 17 operational districts of USAID target areas. In 2005, Cambodia maintained a TSR of greater than 85 percent and increased its CDR to 64 percent. USAID initiated pilot activities to engage drug sellers and pharmacies in DOTS in 2005 and continues to support the national TB program to strengthen its capacity, develop its communications strategy, and produce materials for public health education. To address the problem of TB-HIV/AIDS co-infection, USAID, the Japan International Cooperation Agency, WHO, and CDC worked together to help the Ministry of Health develop a framework for managing TB-HIV/ AIDS and expand implementation of TB-HIV co-infection activities from four to 11 provinces. Results from these provinces have already begun to influence national policy and guidelines for TB-HIV/AIDS co-infection.
- Georgia – USAID assistance to TB control in Georgia increased the CDR in Tbilisi, the capital, from 44 percent in 2003 to 66 percent in 2005. Through the establishment of "DOTS Spots," DOTS coverage in Tbilisi increased from 28 to 91 percent, resulting in an increase in the TSR from 60 to 71 percent. "DOTS Spots" are stand-alone centers or centers located in primary health care facilities designed to increase patients' privacy and hence their willingness to adhere to TB treatment. In addition, as of 2005, food incentives had reached approximately 1,000 needy patients in Tbilisi. Starting in 2006, the Global Fund's TB project will begin assuming responsibility for the food incentives program, which is envisioned to cover the whole country in two to three years. A USAID partner will provide technical assistance to the Global Fund project to implement an incentives program to improve TB treatment completion throughout the country.
- Indonesia – USAID works closely with the Indonesian government and the USAID-funded TBCTA to support DOTS expansion. USAID activities are focused in the large provinces of East and Central Java, each with a population of more than 30 million. Assistance includes strengthening of diagnostic services, human resources, drug management, local government commitment, and operational research. TBCTA also provides DOTS training and laboratory strengthening in West Java and Lampung. The TBCTA-assisted program has achieved impressive results. Central Java's CDR increased from 29 percent in 2003 to 39 percent in 2004 and East Java's from 29 to 40 percent during the same period. The TSR also continued to improve, increasing from 74 percent in 2003 to 81 percent in 2004 in Central Java and from 71 percent in 2003 to 75 percent in 2004 in East Java. In Lampung, the CDR jumped from 25 percent in 2003 to 40 percent in 2004, and in West Sumatra from 43 to 61 percent. Progress in these provinces has contributed to improved performance at the national level, where the CDR increased from 28 percent in 2001 to 52 percent in 2004. Support for laboratory strengthening has resulted in improved laboratory performance, with error rates on average below 5 percent. USAID and TBCTA have also succeeded in incorporating DOTS into the curricula of 24 medical and nursing training schools.
Improving access to TB drugs
Access to TB drugs of assured quality is a key component of DOTS – The Global TB Drug Facility (GDF) provides free TB drugs to programs in need. In fiscal year 2005, USAID provided $4.7 million – 20 percent of GDF annual revenue – for the purchase of TB drugs. As a result of USAID and other donor support, the GDF has approved 85 grant applications since it was founded in 2001, supporting more than 4.2 million patient treatments. In addition to grants for TB drugs, the GDF direct procurement mechanism enables governments, NGOs, and donors to purchase GDF drugs at discounted GDF prices and to benefit from GDF's quality assurance and technical assistance. Since it was launched in 2003, the direct procurement mechanism has generated nearly $17.5 million in procurement business, including procurements funded through Global Fund TB grants. USAID supports a full-time procurement adviser to the GDF as well as drug management technical assistance to GDF recipients. During 2005, the GDF carried out assessment and monitoring visits to 60 recipient countries and organizations.
Increasing, Strengthening Resources
Leveraging the Global Fund – By helping countries access and use TB resources provided by the Global Fund, USAID has increased the impact of Agency funds for TB control. Advocacy, communications, and social mobilization (ACSM) have traditionally been overlooked components of TB control. In 2005, USAID helped support technical assistance and a workshop to train consultants to help countries develop ACSM plans and components for inclusion in their Global Fund proposals. As a result of a modest investment of $120,000 by USAID and other partners, the Fund approved seven TB proposals with robust ACSM components for a total of $24 million over two years for ACSM alone. In its Eastern Europe and Eurasia region, USAID helped three countries develop TB proposals to the Fund, resulting in approvals of two-year grants of more than $18 million. Finally, a USAID partner helps Global Fund grantees prepare procurement and supply management (PSM) plans. In 2004, Global Fund procurement officers realized that inadequate PSM plans were hindering grant implementation. As nearly half of all approved grant funding is allocated for pharmaceuticals and other commodities, the Fund urgently requested support to help grantees develop PSM plans, and USAID has helped organize and support regional workshops to guide countries in preparing plans. To date, more than 500 participants from 74 countries have participated in workshops in Barbados, Ethiopia, Kenya, Lebanon, Nigeria, Tanzania, and Thailand.
Mobilizing political will and support for TB control – Several key events raised the global profile of TB in 2005. In August, the health ministers of Africa declared TB a regional emergency, and the Stop TB Partnership prepared a "Blueprint for Africa" detailing the actions needed to accelerate TB control in the region. After more than a year of intensive work by the Stop TB partners, the Global Plan to Stop TB, 2006–2015, was launched in January 2006 at the World Economic Forum in Davos, Switzerland. Building on the achievements of the first global TB plan (2001–2005), the new plan will serve to inform, advocate, and unite coordinated actions in global TB control. The Plan's goals include the following: 50 million TB patients will be treated; 14 million extra lives will be saved through higher-quality care; and substantial progress will be achieved in new drugs, diagnostics, and vaccines. USAID is highly engaged in the Stop TB Partnership, serving as Chair of the Coordinating Board, participating in all of the Partnership's technical working groups, and contributing significantly to the development of the 2006–2015 plan.
New Tools and Approaches
USAID supports critical research for accelerating global expansion of the DOTS approach to TB control. Working with its partners, USAID focuses its support on developing, evaluating, and introducing tools and approaches that: 1) are appropriate for low-resource countries; 2) have the potential for significant public health impact; and 3) have traditionally been underfunded by the public and private sectors. USAID's current priorities focus on new drug development, improved TB diagnostics, and approaches to program performance.
Strengthening DOTS through public-private mix – Public-private mix (PPM) is an innovation to increase case detection and treatment success rates in DOTS programs. It aims to expand the involvement of all providers in DOTS through public-private, private-private, and public-public mix approaches. USAID has been a leader in testing and advancing PPM approaches through its support for pilot activities in countries such as Cambodia, Kenya, India, Vietnam, and the Philippines; monitoring and evaluation of PPM; data analysis and synthesis; and documentation of lessons learned. PPM is being scaled up in four USAID-assisted priority countries (India, Indonesia, the Philippines, and Kenya), and pilots are underway in 13 more. The most noteworthy example of the impact of PPM is the Philippines, where the CDR has increased from 62 percent in 2002 to 72 percent in 2004. The country thus surpassed the global case detection target of 70 percent, an achievement that would not have been possible without USAID support for PPM. During 2005, guidelines on implementing PPM DOTS were launched, and the cost-effectiveness of this intervention was demonstrated. PPM has been fully integrated into the new Stop TB strategy and the Global Plan to Stop TB, 2006–2015.
New drug development – The currently available TB drugs have been on the market for more than 40 years. TB treatment lasts six to eight months, which is a challenge to patient adherence and a real hardship for patients and their families. In 2005, USAID provided $2 million to the Global Alliance for TB Drug Development, a public-private partnership that develops new compounds and drugs to treat TB. With more than $45 million in grants and $28 million in in-kind contributions from industry and governments, the Alliance made important progress in 2005 in discovering new compounds to treat TB and initiated a phase I clinical trial of PA-824 and a phase IIB clinical trial of moxifloxacin. If proven to be safe and efficacious, these compounds and drugs could shorten the duration of TB treatment to two to four months.
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