Report of TAG, STBP, AIDES Satellite titled
“TB/HIV Programs: Working together to achieve Universal Access to HIV and TB Prevention, Care, and Treatment.”
October 14, 2008
“Communities need to take up the challenge to ensure that country level programs on TB and HIV work together.”
That was the wake up call from Dr Elizabeth Madraa, formerly of Uganda’s AIDS Control Program, to attendees of the TB/HIV Satellite organized by the STOP TB Partnership (STBP), AIDES, and Treatment Action Group (TAG) prior to the 39th Union World Conference on Lung Health held in Paris on October 14, 2008.
The theme of the satellite was “TB/HIV Programs: Working together to achieve Universal Access to HIV and TB Prevention, Care, and Treatment.” It brought together national TB and AIDS control program personnel, researchers, policy makers, funding agencies, and TB/HIV community advocates. Discussions at the Satellite session centered on the challenges faced and lessons learnt by the TB and HIV programs and their partners as they worked together to implement TB/HIV collaborative services.
By highlighting the challenges confronted by programs and examples of effective programs from TB/HIV high burden countries, the satellite focused on the obstacles hampering the roll out of TB/HIV services and how some have been overcome through collaboration and political will. The goal of the satellite was to arm the participants with these examples to help inform their discussions during the rest of the conference, where many of these challenges to TB/HIV collaboration would be further discussed.
In their opening remarks, both Mark Harrington of TAG and Marcos Espinal of the STOP TB Partnership acknowledged that gaps still exist in TB/HIV collaboration at global levels with issues such as lack of full coordination between the TB and HIV programs at the WHO level hampering progress. Harrington pointed out that the “blame game” needs to stop, and instead efforts need to be tailored towards strengthening the response at country levels.
“While it’s good to discuss collaboration in Paris, the real work on collaboration will need to happen at country level,” observed Espinal. He cited demonstrations that focused on TB/HIV at the Cape Town Conference in 2007 and the Mexico AIDS conference in August, 2008 as evidence of a growing TB movement and the rising profile of TB in international meetings. Espinal, however, noted that Civil Society Organizations (CSOs) will need to do more work in boosting movements at the country levels, to demand for government accountability and push them to strengthen TB/HIV collaboration. He also identified the need for activism to be supported on the national level and spoke about the Civil Society Challenge Facility grants that are provided by the STBP as one such mechanism created to support and sustain Non Governmental Organization’s (NGOs) TB/HIV advocacy initiatives at country level.
Discussions during the satellite were divided into four panels:
- Impact of TB/HIV on HIV Universal Access and Global Plan Goals;
- Reducing the Burden of HIV among People with TB: Challenges, Successes, and Lessons Learned;
- Reducing the Burden of TB among People with HIV: Challenges, Successes, and Lessons Learned;
- Resources to Facilitate Collaboration to Achieve Universal Access to TB/HIV Services
Panel 1: The impact of TB/HIV on HIV Universal Access and Global Plan goals, Javid Syed, TAG, USA. Chair
- AIDS Program Manager perspective on the importance of achieving TB/HIV goals
Elizabeth Madraa, AIDS Control Program, Uganda
- Affected communities’ contribution to TB/HIV collaborative services
Carol Nyirenda, TALC, Zambia
- International Health Partnership: Impact of broader health systems issues on TB/HIV collaboration
Sue Perez, TAG, USA
Sue Perez of Treatment Action Group provided an overview of the International Health Partnerships (IHP+) and the impact of broader health systems on TB/HIV.
Launched in September 2007, the key goal of IHP+ is to support countries to reach the health related indicators of the Millennium Development Goals (MDGs). IHP+ seeks to achieve its aims by increasing financing for health and fulfilling the principles of 2005 Paris Declaration that focus on country ownership and leadership in the development, implementation, and evaluation of national development plans. IHP+ aims to achieve harmonization of various existing mechanisms and initiatives to deliver, implement, and monitor aid. Fourteen developing-country governments have already signed on to the IHP+.
Perez acknowledged that since inception of the IHP+, several concerns have been raised about its roles and functions. For instance, CSOs have raised the concern that the IHP+ represents a shift of resources from strategies that are disease-specific to those oriented to Health System Strengthening (HSS), and favors a deliberate shift to pooled financing and Sector Wide Approaches (SWAP) in the name of country ownership. Though noting that these concerns are valid, she observed that focus areas of the IHP+ aimed at Health System Strengthening and Donor Coordination present both challenges and opportunities.
Responding to concerns that IHP+ could mean potentially less donor money directed to TB/HIV programs, Perez made the case that strengthening disease-specific programs will actually contribute to health systems strengthening by keeping the focus on the real causes of illness and mortality. She also addressed concerns that IHP+ could impact the level of funding available to civil society groups at country level for TB/HIV work. Perez provided a list of recommendations to TB and HIV program managers as well as civil society groups. The take home message: “Civil society TB/HIV advocates must be involved in IHP+ discussions with the Ministry of Health to ensure TB-HIV is a priority.”
The case for more effective collaboration was also forcefully put forward by Dr Elizabeth Madraa, formerly of the Uganda AIDS Control Program, as she shared perspectives from her country’s experience in TB/HIV collaboration.
In Uganda, HIV infection among TB patients ranges between 50 70%, with 70% of hospital admissions and approximately 30% of deaths in people with HIV due to TB.
Since setting up a TB/HIV program in Uganda, Madraa noted that the collaboration had helped improve the quality of program management of both NACP (the HIV/AIDS program) and NTBLP (the TB program), as well facilitated the ability of both programs to monitor the trends of TB/HIV collaboration. Data presented indicated that 75% of districts are reporting on HIV testing among TB patients, although, she said, surveillance of HIV prevalence among TB patients still needed improvement.
Other achievements of TB/HIV collaboration in Uganda include the identification of TB/HIV focal points in HIV/AIDS and TB units; provision of infection control (IC) services in collaboration with teaching hospitals, as well as the establishment of monitoring and evaluation systems for tracking both programs.
However challenges in TB/HIV collaboration still exist in Uganda. These include weak human resource capacity; lack of standardized tools for monitoring and evaluation in both programs, and conflicting demands for information from internal and external agencies, which places additional burdens on the programs.
Madraa also identified specific factors that needed to be addressed to improve TB/HIV collaboration. These factors include establishing mechanisms for sharing information and collaboration and increasing human resources to manage the patients, particularly the need to hire more nurses.
To scale up current efforts, additional measures such as improving data collection at HIV treatment sites, screening all patients in general antenatal clinics (ANC) and in HIV care centers for TB, and developing creative and innovative ways of addressing gaps in the health system need to be put in place. “We may have the frameworks, but if we don’t work together, we cannot make progress,” Madraa noted.
But Carol Nyirenda of Treatment Advocacy and Literacy Campaign (TALC), an advocacy group based in Zambia, believes that innovative ways to scale up access to TB/HIV services should not be targeted towards health care workers and health systems alone. “We need to de-medicalisze TB. TB has been in the doctors books for too long and information should be repackaged to benefit the community,” she said.
Through her talk titled “Affected Communities Contribution to TB/HIV Collaborative activities,” Nyirenda pointed out that community response has long been a cornerstone of the scale-up of the HIV response, and the TB community needs to borrow from the HIV program by utilizing the existing structures among affected communities, such as PLWH support groups, to build TB treatment literacy as well as create demand for TB/HIV services.
Nyirenda also discussed the outcomes of research conducted by TALC in Zambia. From the findings of research conducted in three provinces in Zambia focusing on the level of implementation of TB/HIV services in the country, TALC identified several gaps: there was no meaningful representation of affected communities in the Joint Collaborating Body on TB/HIV in Zambia; information on TB/HIV coinfection was lacking; and TB and HIV services were still operating separately.
TALC utilized several approaches to redress the situation. Tactics employed included training HIV activists and health care workers on TB treatment literacy, setting up TB desks at HIV clinics and HIV desks at TB clinics to provide coinfected patients with relevant information, and convening meetings with both TB and HIV program managers.
Nyirenda also outlined several roles that communities can play to support effective TB/HIV collaboration. These include: creating an activist movement, which can increase demand for access to TB/HIV collaborative services; facilitating the formation of TB support groups for adherence and treatment support; calling for infection control and intensified case finding; as well as facilitating the emergence of “TB champions” who can contribute to the reduction of TB related stigma.
Nyirenda emphasized the need to support communities to enable them to deliver on these tasks. “Communities need to be trained. PLWH and those affected by TB are the ultimate beneficiaries of these services and our unique strengths will be critical to the successful TB/HIV collaboration,” she said.
Responding to the issues raised by the panelists, Ezio Dos Santos Filho, an activist from Brazil, asked about the obstacles to implementing isoniazid preventive therapy (IPT) and what plans exist to expand access to IPT. Oba Oladapo of the Positive Life Association of Nigeria (PLAN) requested details on how the Ugandan program plans to engage the clinical officers and how TALC Zambia succeeded in setting up TB support groups. Matt Kavanagh of RESULTS also asked if TB screening services are offered to those accessing HIV services in Uganda on a regular basis.
Speakers responses to the questions raised are outlined below:
In response to the question about IPT and TB screening services, Dr. Madraa said that, “Uganda faces a peculiar challenge because most of the health workers are not competent to diagnose active TB. Studies have shown that IPT is being administered in eight centers. However, the challenge is that the responsibility for isoniazid (INH) administration really lies with the TB program, and, as INH is one of our treasured drugs, we don’t want to mess it up.” Dr. Madraa also discussed the fact that there had been a stock-out of HIV test kits in Uganda, which impacted the program’s ability to act as a point of entry for TB screening. Dr. Madraa explained that the guidelines in use could also be faulted, as screening for TB is now being done, but it is not being reported.
Dr. Madraa said that at lower levels of the health system there is a lack of trained personnel for ART care and there is need to train people who can multitask in order to address the human resource gap. She also noted that Uganda has a framework for collaboration and that several partners support joint planning activities. For her part, Nyirenda noted that in the initial stages of developing TB advocacy, HIV structures can be utilized to build on the leadership of PLWHA, who are at great risk for TB related disease and death. TALC, in creating their support groups for people with TB/HIV, also ensured that former TB patients were part of the process.
Panel 2: Reducing the burden of HIV among people with TB – Challenges, Successes, and Lessons Learned. Alasdair Reid, UNAIDS, Switzerland. Chair
- HIV testing and risk reduction for people with TB: What works, how can it be improved
Lakhbir Singh Chauhan, NTP, India
- Impact of providing ARV and CPT for persons with TB/HIV: Public and NGO partnerships
Greet Vandebriel, ICAP, Rwanda
- HIV activist leadership in provision of TB/HIV treatment literacy and support in the context of stigma and fear of TB infection
Victor Lakay, TAC, South Africa
Speaking on “HIV testing and risk reduction for people with TB; what works, how can it be improved. Progress in India,” Dr. Lakhbir Chauhan, Program Manager of India’s National TB Program, gave a brief overview of the TB and HIV situation in India. He noted that the HIV rates among TB patients vary based on region. Results from a 2006-2007 HIV prevalence survey among TB patients from several provinces in India indicated that the HIV prevalence ranges from 1-14%. He added that the fact that the HIV burden differs in different parts of the country indicates that diverse and localized strategies are required.
In responding to the dual epidemic, India has focused on scaling up TB/HIV activities nationwide as well as on an intensified TB/HIV package for high HIV burden states. For instance, high HIV burden states have a policy of routine referral of all TB patients with unknown HIV status for HIV testing, whereas in other states, providers assess TB patients for HIV risk factors before referrals.
Part of India’s response has been a pilot study of the provision of cotrimoxazole preventive therapy (CPT) for HIV-infected TB patients. The study, which was conducted in 2007 in three districts within Andhra Pradesh, a province with a generalized HIV epidemic, showed successful initiation of CPT. Among the 735 HIV-positive TB patients enrolled, 704 (96%) were initiated on CPT. However, despite successful initiation of CPT, adherence was rather poor.
Chauhan outlined some lessons for scaling up interventions to reduce the burden of HIV in TB patients. He noted that his country’s experience shows that detection of HIV cases can be effectively improved through routine referral of TB patients to HIV counseling centers. He however noted that a key challenge is linking HIV infected TB patients to HIV care (for both CPT and ART).
To achieve universal access to TB/HIV services nationwide, Chauhan recommended the following: implementing intensified TB/HIV efforts, which includes training medical and paramedical personnel on new TB/HIV interventions; improving linkage of HIV/TB patients to ART; engaging the TB program to monitor ART for HIV/TB patients; addressing airborne infection control in ART centers; and conducting trials in order to generate evidence for operationalizing IPT in ART centers.
Provision of ART and CPT for persons with TB/HIV through public and NGO partnerships was the focus of the talk by Dr. Greet Vandebriel of the International Centre for AIDS Care and Treatment Programs (ICAP), Rwanda.
Key strategies employed by ICAP include: the creation of a coordinated and centralized technical assistance program through the establishment of a national TB/HIV technical working group, development of relevant policies, guidelines, and training materials, and the implementation of TB/HIV model centers.
Dr. Vandebriel explained that the ICAP program designed a one-stop center for TB patients with HIV within the TB program. This implied that TB patients could readily access HIV voluntary counseling and testing (VCT). TB patients who are confirmed to have HIV can also access medical consultation and prescriptions for CPT and ART within the center. On completion of TB treatment, the patient is referred and/or accompanied to the ART clinic for further follow up. In addition, home visits are provided for TB patients with HIV at the initial stages and HIV testing services are offered to family members of such patients.
Challenges faced by the program, as explained by Vandebriel, include coordination of efforts with the broader HIV and TB program in the Rwandan Ministry of Health, expanding the full coverage of the one-stop services for TB patients, as well as the lack of sufficient human resources to supervise the program and monitor its outcomes.
While expanding access to care for TB/HIV patients is crucial, such care must be provided within a human rights context, observed the next panelist, Victor Lakay of the South African based Treatment Action Campaign (TAC).
Speaking on the topic “HIV activist leadership in the provision of TB/HIV literacy,” Lakay provided participants with an overview of the TB epidemic in South Africa, noting that human rights violations have determined the course of the epidemic in the country. Lakay pointed out that, despite having a constitution that explicitly states that “everyone has a right of access to health care services,” a belief that HIV does not cause AIDS among some political leaders in South Africa had led to inaction, making it difficult for programs to effectively respond to the epidemic.
While TAC has been able to draw attention to the magnitude of the TB problem through a variety of advocacy efforts and initiatives–such as the establishment of TB support groups, treatment literacy efforts, development of policy briefs on infection control, intensified case finding, and prioritizing of TB on the SANAC (SA National AIDS Council) agenda–several challenges still exist that South Africa’s TB program will need to address. Key areas for urgent intervention by the South African TB program include identification of emergency measures, particularly with respect to infection control, case finding, isoniazid preventive therapy (IPT), and drug susceptibility testing for people failing on TB treatment in regions with high incidence of TB drug resistance. “Infection control is still focused on health facilities and clinics, and there is a need to engage communities in this process,” he observed. He also identified implementation of TB/HIV collaborative activities, development of a human resource plan for TB, and needs-based planning and budgeting as areas requiring urgent attention.
Providing a summary of key points highlighted by the speakers during the panel, the session’s discussant, Dr. Bobby John, of Global Health Advocates, India, noted that, given the varying nature of the country experiences discussed and the varying TB/HIV epidemiology, it is evident that the “nature of the epidemic at country levels will determine the response.” He noted that, while the nature of TB/HIV collaboration may vary from country to country, case finding, comprehensive programming, and responsible referrals remain areas of importance that both TB and HIV programs need to prioritize.
“In calling for universal access for HIV/AIDS care, TB seems to be left out. Why has it taken so long for the HIV community to include TB?” asked John, who emphasized the need for both TB and HIV programs to break down the traditional barriers that have divided them.
He also identified several best practices from the HIV programs that the TB programs will need to take on board. These include embracing activism and developing a mechanism for collaboration that involves all types of actors–health care workers, communities, grandmothers, etc.–as well as promoting the establishment of accountability mechanisms.
The HIV program also needs to emulate some good practices from the TB program as well. Such practices include the administrative will to roll out programs, mobilization and decentralization, greater contribution from all sectors, efficient laboratory management, as well as data integration.
John also observed that “TB/HIV collaborative activities fall in a ‘no man’s land,’ because in most countries, collaborative activities are not handled by anyone specifically,” adding that there is need to push for a resource envelope that specifically tasks people to take responsibility for TB/HIV.
He also called for concentrated efforts in the area of treatment literacy for community advocates. “We can make referrals but without community involvement, the clients will be lost,” he added.
A series of questions followed the panel presentations:
In scaling up ART and vis-à-vis infection control issues, how can countries act more responsibly by not sending their multidrug resistant (MDR) TB cases across the border to neighboring countries? How are affected communities being involved in the TB/HIV programs at country level? Is there evidence that TB/HIV collaboration is actually strengthening health system? How are the affected communities engaged at policy levels and to what extent is the Patients Charter used? Should we set up a separate TB/HIV entity, and if so, where would it sit?
Responding to the various questions, panelists noted that to forestall the trend of cross-border transfer of MDR-TB cases, systems should be put in place to ensure that governments takes responsibility for MDR cases and that there be cross-border cooperation to facilitate the transfer and management of mobile populations.
On the impact of TB/HIV collaboration on the health system, speakers noted that collaborative TB/HIV has helped to strengthen monitoring and evaluation capacity, laboratories, and provider-initiated testing, thereby contributing to improving the health system as a whole and not just the vertical programs. In South Africa, it was noted, health care services are working with the Department of Housing to address infection control and improved housing for TB patients. Panelists also noted that affected communities are involved in the technical working groups.
Responses to the creation of a separate TB/HIV entity also raised more questions. One strategy discussed was the potential to reinstate the TB/HIV funding track of the Global Fund. However, it was noted that the past experience of the Fund needs to be understood before advocating for this separate funding.
The panel ended with a recommendation to increase community demand for and involvement in TB/HIV collaborative activities as a way to challenge the TB community’s reluctance to take up new technologies and new ways of thinking.
“It’s time to have a multiplicity of delivery channels. The TB program is regimented and thinking only in one particular line–and it needs to break out of that line of thinking,” noted Bobby John.
Panel 3: Reducing the burden of TB amongst PWH: Challenges, Successes, and Lessons Learned, Carole Mitnick, Harvard Medical School, USA. Chair
- Isoniazid Preventive Therapy: What can be learnt from the Rio de Janeiro experience?
Betina Durovni, City of Rio de Janeiro Dept. of Health
- Addressing MDR TB in the context of HIV: Lessons from Lesotho
Hind Satti, PIH, Lesotho
- Infection Control and Intensified Case Finding: Notes from Kwazulu Natal. What do we know, what can we do now?
Tony Moll, Church of Scotland Hospital, South Africa
The 3rd panel featured experience sharing from three different areas: Rio De Janeiro, Brazil, Lesotho, and Kwazulu-Natal in South Africa.
Betina Durovni, of City of Rio de Janeiro Department of Health, shared with participants the experience of the City of Rio de Janeiro in providing isoniazid preventive therapy (IPT) through the public HIV clinics.
According to Durovni, data indicates that TB is a primary cause of death people with HIV in Rio de Janeiro (in 2005, 58.7% of deaths among people with HIV were due to TB). High population density in the area and a high percentage of people with HIV, as well as the existence of an IPT policy, provided the initial push to initiate a phased IPT implementation trial in Rio.
In analyzing the barriers to IPT, an assessment of physician’s adherence to HIV and TB guidelines in Rio was conducted. Data from this assessment presented at the 2007 IUATLD Conference showed that doctors in Rio de Janeiro were much more willing to prescribe CPT (a 97% rating) compared to IPT, which recorded a mere 11% rating.
With the primary goal of decreasing TB among HIV positive individuals, strategies employed by the Department of Health and its partners in scaling up IPT included training of health workers in TB/HIV counseling, establishment of a community advisory board (CAB), and the development of educational materials.
A key lesson learned from the process was that the lack of doctors’ knowledge on the TB prevention protocol, as well as their misconceptions about the adverse effects of INH on HIV patients, was a barrier to the implementation of the IPT.
Over a two-year period, the pilot program was able to place about 1,253 clients receiving ART on IPT in Rio de Janeiro. This pilot program also presented an opportunity to improve on TB case finding, as data presented also show that since September 2005, 11.4% of all TB cases diagnosed among HIV patients were found in the process of ruling-out TB disease before starting IPT.
In addition, the project has also learned the importance of analyzing the process, having clear steps at the facility level to ensure effectiveness, and developing appropriate messaging in concert with the TB and HIV programs.
Dr. Hind Satti of Partners in Health (PIH) provided perspectives from Lesotho’s efforts in addressing multidrug resistant TB (MDR-TB) in the context of HIV.
Lesotho has a high burden of TB and HIV with a HIV prevalence of 23.2% (in 2005) and up to 80% prevalence of TB among people living with HIV.
Besides addressing the poverty related issues, the Partners in Health program dealt with barriers to care, including the poor diagnosis of TB and MDR-TB in patients with HIV, the lack of facilities to care for very sick patients, a lack of mechanisms to deliver MDR-TB care, poor infection control in a HIV care settings, the shortage of trained human resources, and migration of Lesotho citizens to work in the South African mines.
In addressing some of the challenges, PIH in partnership with the Ministry of Health of Lesotho, the Foundation for Innovative and New Diagnostics (FIND), and Open Society Institute, built a laboratory with capacity for mycobacterial culture and drug susceptibility testing; refurbished an existing hospital to create an MDR-TB/HIV center of excellence, and made provisions for in-patient care. Infection control efforts were improved by providing masks for all staff and state-of-the art ventilation in facilities. PIH is also implementing Direct Observed Therapy (DOT) for MDR-TB patients via community-based care using community health care workers.
A community based care strategy also provides psychosocial support, screening of household contacts, and accompaniment of patients for clinical visit. The program also supports clients through assistance with food, housing, fuel, and transportation.
Satti emphasized the need to take the patient’s concerns into perspective in delivering care, particularly for those with MDR-TB. “Patients need to go to their homes and we need to ensure that they adhere to treatment, and the only way to do this outside the hospital setting is community-based management of MDR-TB.”
Regarding its successes, Satti said that the decentralized program currently has over 200 patients enrolled on treatment, with 30% drawn from mining companies in neighboring countries. Eighty percent have MDR-TB and coinfection with HIV, yet no default cases have been recorded. All the TB/HIV coinfected patients are started on ARVs regardless of their CD4 count; the program also relies heavily on community health workers and has trained over 2000 of them.
Satti, however, expressed concerns about the adverse working conditions in the mining and construction companies, where about 30% of their patients are currently employed. Although efforts had been made to discuss the working conditions with the management of these organizations, the companies have not undertaken any major efforts to improve on the conditions.
Dr Tony Moll of the Church of Scotland Hospital South Africa also shared perspectives from Kwazulu Natal (Tugela Ferry) on Infection Control and Intensified Case Finding (ICF)
Integration of TB and HIV services is a key consideration in taking care of HIV infected patients with TB coinfection. However, “integration of TB and HIV services need to be done with care while ensuring that infection control measures take into cognizance both administrative and environmental protection,” he explained.
Moll observed that designing environmental controls implies manipulating the air the patient breathes. The preferred IC options would be to maximize the natural ventilation by opening all windows as well as decongesting the space to ensure that patients get more air around them.
He noted that to achieve success in intensified case finding, programs need to step up their surveillance activities and engage the communities in order to find active TB cases. “We can’t afford to remain within the hospital and expect to improve on our case finding,” Dr. Moll said.
Summarizing the issues raised during the panel, the discussant, Paula Akugizibwe of the AIDS Rights Alliance for Southern Africa (ARASA), observed that an underlying theme of the various presentations showed that, without the required level of engagement, even the best strategies to care for coinfected patients would have little impact.
She also pointed out that the knowledge of these strategies and lessons learned need to be filtered down to ensure accountability. Practical approaches for ensuring that such knowledge translates to action will include developing guidelines or models of care that respond to context-specific challenges, patient-centered approaches to facilitate treatment, as well as mechanisms to address cross border management of TB/HIV.
Akugizibwe also emphasized the need for greater community mobilization and involvement in addressing the challenges posed by coinfection. “You cannot get away from the HIV message. It’s always there. The information about TB is not there. We are ‘exporting’ MDR-TB cases from one country to another as migrant workers move or are deported to their countries. It’s important that we put those who qualify for ART on treatment in order to reduce the risk of TB and MDR-TB”, she said.
Panel 4: Resources to Facilitate Collaboration to Achieve Universal Access to TB/HIV services, Mark Harrington, TAG, USA. Chair
- Retooling and Research: How can we scale up access to new tools to address TB/HIV
Dave Muthama, NTLP, Kenya
- Joint planning for TB/HIV collaborative activities: Lessons from Stop TB Partnership’s TB Team on GFATM TB/HIV grants
Andrea Godfrey, TB Team, Stop TB Partnership, Switzerland
The final panel addressed the crucial question of resource mobilization for TB/HIV against the 2010 deadline. With only two years left, how do we get the resources to meet the goal of universal access?
Dr. Caroline Ryan, Director of Program Services at the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) had some good news to offer. According to her, the recent reauthorization policy from PEPFAR, which pledges up to $48 billion to fight the three diseases of HIV/AIDS, TB, and malaria, presents a window of opportunity to scale up TB/HIV funding as well as provide resources for more countries. She noted that over the past four years, PEPFAR’s support for TB/HIV programs has increased by almost 700%, growing from $18.8 million in 2005 to $169 million in 2008.
In responding to the TB/HIV epidemic in the 15 PEPFAR focus countries under the initial phase, funding has been utilized to address specific interventions such as provision of HIV testing for TB patients, supporting cotrimoxazole and isoniazid preventive therapy (IPT), conducting TB drug resistance surveillance surveys, implementing effective TB infection control services, improving laboratory systems for detection of MDR-TB cases, as well as strengthening TB/HIV laboratory capacity.
Drawing from the experiences of countries currently being supported by PEPFAR, Ryan noted that that to ensure effective scale up of collaborative activities, countries will need to address the fundamental issues by developing national policies and guidelines as well as recording and reporting tools. Apart from the setting up “one-stop centers” for effective collaboration and target-setting by both TB and HIV programs, the human resource gap needs to be filled through health care worker recruitment, training, support and task shifting.
Additional areas that need strengthening include increasing HIV care and treatment uptake; early initiation of ART for TB patients who test HIV positive, harmonizing all the indicators (particularly in situations where Ministry of Health (MOH)/NTPs, donors and PEPFAR have varying indicators), as well as addressing the MDR-TB threat.
With an array of outdated test which make diagnosis of TB in people with HIV difficult, the need for new and more sensitive tools is critical to mitigate the impact of TB/HIV. As new tools are evolving, country programs need to be supported to embrace and utilize these tools to ensure more efficient detection of TB cases as well as reduction of transmission.
In discussing the rationale for utilizing new tools as an effective intervention, Dave Muthama of the Division of Leprosy, Tuberculosis and Lung Disease from the Kenyan Ministry of Health, took participants through the Kenyan TB Program’s experience in the use of two new tests, namely the liquid-culture-based BACTEC MGIT and the HAIN test.
Kenya’s experience showed that there was a need for increasing the sensitivity of the TB diagnostic test and reducing the time to diagnoses. The liquid culture test MGIT provided a solution for these two issues, as it is highly sensitive and provides a positive result in 11 days as opposed to 4-6 weeks that the solid culture test takes. However, the cost of the MGIT test and the level of laboratory infrastructure required prevent the test from being decentralized. In addition, using this technique also raised concerns about quality assurance and quality control as there are no supranational laboratories in the region (whereas it is required that liquid culture test results be sent to a supranational laboratory for verification).
The HAIN test has also has a much shorter turn-around time for detection and offers a promise of increasing the number of sputum samples analyzed. However, the roll-out of the HAIN test has also been limited due to its cost and technological demands. Despite these constraints, the Kenyan NTLP has been rolling out these tests in referral laboratories. Dr. Muthama recommended that the NTPs be informed about the new tools being researched and assess their appropriateness to address the specific challenges and constraints faced by the country.
Andrea Godfrey of WHO’s STOP TB Department and the TB Team provided a summary of steps taken to develop a joint TB/HIV proposal for the Global Fund Round 8 call for proposals on TB, and also stressed the need for countries to develop ambitious TB proposals for Round 9, because, though the funds are available from the Global Fund, the TB programs often do not request enough funding.
Providing a summary of the last session and recommendations on the way forward, Mark Harrington of the Treatment Action Group (TAG) and co-convener of the meeting challenged the various actors to rethink their strategies if true collaboration is to be achieved. “CSOs have complained that TB is medicalized. They need to be given support to de-medicalize it. TB is more focused on implementation than advocacy and we need to maintain a good balance between the two. We need to invest more in research and massively scale up. We need to end the diseases and not just control them,” he added.
Though realities and challenges in several countries were discussed during the meeting, the emerging themes reinforced the need for greater political leadership and commitment as well as concerted efforts from countries in order to meet the target for Universal Access for TB/HIV services by 2010. Cross program partnerships and partnerships with CSOs were two common strategies identified to partially address the constraints of health care systems and to improve program outcomes through support for treatment completion and case detection. Furthermore, bottom-up demand for services and new tools were also seen as potential strategies that could be borrowed from the HIV movement. Such concerted efforts must address the lack of skilled manpower (particularly health care workers), and weak monitoring and evaluation systems, as well as focus on strengthening the collaboration between TB and HIV programs, partners, civil society actors and all key stakeholders. There were many examples of political leadership on the part of the NTPs that have helped moving the programs closer to Universal Access. The increased HIV testing of TB patients in many countries, the roll out of IPT in the HIV clinics of Rio, the implementation of infection control and intensified case detection at the Church of Scotland Hospital, and ART provision by the ICAP program in Rwanda through an integrated care site for TB/HIV coinfected communities all provided concrete ways in which political leadership when working in partnership can address major obstacles in providing TB/HIV collaborative services. The key message of the impact that political will and partnership could have on improving program outcomes was also well illustrated by Lesotho’s MDR-TB program. This program showed how a challenge as difficult as MDR-TB in a high-burden HIV area is being addressed through a real partnership involving the Lesotho Ministry of Health, community-based health care workers, program implementers (Partners in Health), product developers (FIND), and funding partners (including OSI). This central message of the satellite was also a challenge for all those present who were asked to consider how they could contribute to such partnerships to ensure that the TB and HIV universal access goals can be achieved.