People, communities and health servicies:together for Tubercolosis care and control in Africa

DOCTORS WITH AFRICA CUAMM People, communities and health services: together for Tuberculosis care and control in Africa

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People, communities and health services: together for Tuberculosis care and control in Africa

DOCTORS WITH AFRICA CUAMM People, communities and health services: together for Tuberculosis care and control in Africa

People, communities and health services: together for Tuberculosis care and control in Africa

Global status of the tuberculosis epidemic and progress towards 2015 targets

The World Health Organization (WHO) estimates that in 2010, there were 8.8 million new cases of tuberculosis (TB) worldwide, including 3.2 million among women and half a million among children less than 5 years old.1 Nearly 1.5 million deaths occurred in the same year, including half a million among women. Some 9.7 million orphans caused

by TB in parents were living in 2010.

Of all cases, 1.1 million or 13% occurred among people living with HIV/AIDS (PLHIV) of whom 350,000 were fatal. More than 80% of these HIVassociated cases were in Africa. About 650,000 cases of multidrug-resistant tuberculosis (MDRTB) were estimated to be among the world’s 12 million prevalent cases of TB in 2010. Extensively drug resistant TB (XDR-TB) has been reported officially from 69 countries. Of the 8.8 million new cases estimated for 2010, 5.7 million were officially reported by national programmes (65% of estimated). Treatment success was 87% among new sputum-smear positive cases, with a wide variation among regions.

Good programme performance should result in an epidemiological impact on incidence, prevalence and mortality. The un-ambitious TB-related 2015 Millennium Development Goal (MDG) of halting and beginning to reverse TB incidence rate is estimated to have been reached already in 2002, and since 2006, also the total number of cases is declining. However, the decline is slow, only 1% per year. On the other

hand, globally, the mortality rate is declining more quickly and the target of halving it by 2015, compared to 1990, may be reached globally and in all regions, except Africa. In 2010, 34% of all TB patients knew their HIV status, including 59% in Africa, and an increasing number of HIV(+) TB cases were enrolled on co-trimoxazole prophylaxis and antiretrovirals. In 2010, an estimated 290,000 of all notified TB cases had MDR-TB. Of those, 50,000 were diagnosed and 46,000 of them (16% of all estimated) were treated according to international standards.

Overall, since the establishment of DOTS (later enhanced to Stop TB Strategy) in 1995, 46 million people have been cured and nearly 7 million lives saved compared to the 1995 performance standards.

These information show that current efforts result in positive outcomes. However, several challenges to TB control exist in 2011, including: financing is not secured, with dependency on international sources by most low-income countries; a third of estimated cases are not diagnosed and reported, thus transmission of the infection may continue; TB/HIV is challenging control in Africa; MDR-TB is threatening achievements world-wide, especially in the former USSR. Furtheremore, health policies, systems and services are weak and are not conducive to TB care and control in many settings. Despite remarkable results in publicprivate mix approaches, non-state practitioners

figure 1

are too frequently un-regulated and un-engaged in good care practices; communities are not mobilised to demand, and contribute to, proper care; research & development and, despite remarkable progress in the adoption of new rapid molecular testing, transfer of tools/ technology is limited at the moment. As a result, despite the achievements of the last decade, Nigeria the TB epidemic continues to remain a major Brazil Dr Congo global health issue, as expressed by the very Zimbabwe slow incidence decline and the high number of South Africa deaths world-wide. A four-pronged approach is needed to foster better control and seriously target elimination. First, TB control programmes must optimize management and care of cases Estimated new cases (all forms) per 100 000 population as described in TB the Stop TB Strategy.

Second, 25-49 50-99 bold policies0-24 and properly resourced services across the health system are crucial to allow core

Russian Federation

TB interventions to be effective. Third, increased investments in research and development of new tools are essential. Fourth, correction of risk factors and the socio-economic determinants of China TB will be crucial towards elimination.

Bangladesh Vietnam Cambodia Philippines

Pakistan Recognizing the scale of the problem, global Afghanistan Myanmar targets forEthiopia reductions in the burden of TB are Uganda Thailand Indonesia amongst Kenia the Millennium Development Goals Ur Tanzania (MDGs n.6).2 The target set within the MDGs is to halt and reverse the incidence of TB by 2015.

Furthermore The stop TB partnership has set Mozambique two additional and more precise targets for 2015: to halve TB prevalence and death rates by 2015, compare to 1990 levels and, looking further into the future, the target of eliminating TB by 2050 _ 100-299 >300 No estimate 3 (defined as global incidence < 1 case/million). practitioners are frequently un-regulated and

1. WHO. Global Tuberculosis Control 2011.

are too frequently un-regulated and un-engaged in good care practices; communities are not mobilised to demand and to contribute to, proper care; research & development. Despite remarkable progress in the adoption of new rapid molecular testing, transfer of tools/ technology is limited at the moment. As a result, despite the achievements of the last decade, the TB epidemic continues to remain a major global health issue, as expressed by the very slow incidence decline and the high number of deaths world-wide. A four-pronged approach is needed to foster better control and seriously target elimination. First, TB control programmes must optimize management and care of cases as described in the Stop TB Strategy. Second, bold policies and properly resourced services across the health system are crucial to effective core TB interventions. Third, increased investments in research and development of new tools are essential. Fourth, correction of risk factors and the socio-economic determinants of TB are crucial to more forward elimination.

Recognizing the scale of the problem, global targets for reductions in the burden of TB are amongst the Millennium Development Goals (MDGs n.6).2 The target set by the MDGs is to halt and reverse the incidence of TB by 2015.

Furthermore the Stop TB partnership has set two additional and more precise targets for 2015: to halve TB prevalence and death rates by 2015, compared to 1990 levels and, looking

4â&#x20AC;&#x201D;5

further into the future, to target eliminating TB by 2050 (defined as global incidence < 1 case/ million).3 The Stop TB strategy, while building on the DOTS (Directly Observed Treatment Short course) strategy, aims at expanding its scope to address the remaining constraints and challenges to TB control, an expansion that is critical to the achievement of the MDG and the Stop TB Partnership targets for TB control.

The goal of the strategy is to reduce dramatically the global burden of TB by 2015 in line with MDG and the Stop TB Partnership targets; the objectives are: - To achieve universal access to high quality diagnosis and patient-centered treatment - To reduce the suffering and socioeconomic burden associated with TB - To protect poor and vulnerable populations from TB, TB-HIV and MDR-TB - To support development of new tools and enable their timely and effective use.

The strategy has 6 major components : 1. Pursue high quality DOTS expansion and enhancement 2. Address TB/HIV, MDR-TB and other challenges 3. Contribute to health system strengthening 4. Engage all health-care providers 5. Empower people with TB and their communities 6. Enable and promote research.

People, communities and health services: together for Tuberculosis care and control in Africa

2. http://www.who.int/tb/ country/mdgs_for_tb/en/ 3. The global plan to Stop TB 2001 â&#x20AC;&#x201C; 2015.

Elements of the Stop TB Strategy and Doctors with Africa CUAMM’s commitments

1. Pursue high quality DOTS expansion and enhancement Expanding and enhancing DOTS, i.e., the essentials of TB care and control, is obviously the cornerstone of the strategy. But to overcome known constraints, further strengthening is required on the following lines: Political commitment with increased and sustained financing – Political commitment is crucial for DOTS implementation and to foster national and international partnerships.

The target is that at least 70% of financial resources needed for DOTS expansion and enhancement should be mobilized by domestic sources, including governments, budget loans and social insurance schemes3. Governments in endemic countries must increase their political commitment and operational support of TB control. Greater investment is needed in innovative ways to accelerate the expansion of DOTS program, including collaboration between public-private health-care providers and mobilization of the civil and community sectors.4 Doctors with Africa CUAMM, thanks to the long experience in collaborating with national and local governments, will help sustain the political commitment at local and national level in order to guarantee access to quality TB care services in all countries where it presently works. According to the Paris Declaration on Aid Effectiveness5, Doctors with Africa CUAMM always harmonize and align its interventions with country priorities and systems to coordinate its activities with local leadership in mutual accountability.

The interventions of Doctors with Africa CUAMM are aimed at strengthening the health system at all levels including technical assistance, capacity building, training of health professionals and operational research, within the frame of the Primary Health Care model.6 In Italy Doctors with Africa CUAMM will inform, involve and urge civil society, professional bodies, private companies, donors and governmental institutions to act upon the issues of TB control in Africa and, help address address, simultaneously, simultaneously, the social and economic determinants of TB through promoting in corporation of health in all policies in the African countries.

Case detection through quality-assured bacteriology – Bacteriology remains the recommended method of TB case detection: a wide network of properly equipped and decentralized laboratories is necessary to ensure access to quality-assured test.

There is a growing need to dramatically expand and strengthen TB laboratory services, including increasing access to high quality microscopy, culture, drug susceptibility testing (DST), and new diagnostics. A major barrier, however, is developing capacity and assuring quality within weak laboratory systems where there are little or no laboratory standards7.

Doctors with Africa CUAMM will continue its effort in strengthening quality-assured laboratory services at hospital and peripheral levels. Doctors with Africa CUAMM will ensure that laboratories in all its managed facilities are up to the standard for the diagnosis of TB Interventions on TB, including facilities, training of health personnel and provision of equipment. Innovation and research in TB diagnostic technologies at hospital level will be promoted. Establishment of higher-level referral system or referral units for culture and DST will be pursued at National or Regional level, where feasible.

Standardized treatment, with supervision and patient support – Standardized treatment services as well as patient support should be enhanced: supervised treatment helps patients to take their drugs regularly and to complete their treatment.

Studies are showing that even when countries have established regimens, non-governmental and for-profit practitioners do not always adhere to those standards8.

In line with Doctors with Africa CUAMM’s strategic plan aimed at guaranteeing access to quality health services, efforts are going to be made to address financial, social and cultural barriers to quality TB treatment and adherence through promoting community mobilization in TB control. Supervision and patient support will be enhanced by integrating hospital services with outreaches and community services. Village Health Workers will also be involved in sensitization, identification and referral of suspected case, contact tracing and follow up, where feasible.

All health facilities supported by Doctors with Africa CUAMM will provide WHO standardized

4. The report of the second stop tb partners’ forum New Delhi, India 24 – 26 march 2004.

5. Organization for Economic Co-Operation and Development.

The Paris Declaration on Aid Effectiveness. 2005.

6. The World Health Report 2008 – Primary Health Care, now more than ever. World Health organization. 2008.

7. The global laboratory initiative, world health organization, stop tb partnership, accessed 2012.

8. Global Drug Facility (GDF) Rationale for standardizing TB drugs, GDF 2008.

treatment for TB. Integration of TB services with HIV, maternal and pediatric services will be guaranteed in all supported health units.

Doctors with Africa CUAMM also recognizes that, besides easier access to free diagnosis and treatment, patients also need to be provided social protection to help prevent and address socio-economic consequences of TB and other illnesses that might have catastrophic impact on patients and their families.

Effective drug supply and management system in addition to these drugs should be available free of charge to all TB patients.

Better monitoring and management of drug supply and distribution are still required.

Improving supply system is among the major stated concerns for health system strengthening in general.9 In line with the effort made by Doctors with Africa CUAMM to strengthen the health system, at district level, the issue of supply chain management of quality drugs will be addressed from local district authorities to point of care, integrating, where possible, this effort with the supply and general management of other drugs and consumables. Where feasible and appropriate, support to the National Tuberculosis Program (NTP) will be provided with technical assistance, participation to coordination/partners meetings and technical workshop. Where necessary the issue of supply chain management will taken into account seeking partnership with actors and institutions expert in this field.

Monitoring and evaluation system and impact measurement – that means establishing a reliable monitoring and evaluation system with regular communication between the central and peripheral levels of the health systems.

Routine monitoring of the performance of TB control is crucial.10 However in situations such as Angola in 2005 only 19% of DOTS facilities were reporting accurate and timely data to central level, demonstrating the need for improvement.11 In all its programs, Doctors with Africa CUAMM pays great attention to the health information system and the promotion of data-driven management. Specifically for TB control, 6—7

attention will be paid to all key indicators from process to impact. No additional, parallel systems of data collection and reporting will be put in place. Strengthening national data collection system supporting, if necessary, the National Tuberculosis Program will be taken into consideration. Existing information systems will be strengthened and where necessary, specific surveys or studies will be planned and undertaken.

2. Address TB/HIV, MDR-TB and other challenges Implement collaborative TB/HIV activities As shown within the epidemiologic data, about 10-13% of patients who died from TB in 2009 were also HIV+. This is because HIV promotes the progression of recent and latent Mycobacterium tuberculosis infection to active TB disease. The HIV epidemic has contributed dramatically to the incidence, prevalence and mortality of TB. HIV and TB are so closely connected that theirs is often described as ‘co-epidemic’. WHO has published a new definitive policy on collaborative TB/HIV activities that addresses 3 categories of interventions to reduce the burden of TB: Establishing the mechanism for collaboration through the creation of a joint national TB and HIV coordinating body that includes TB and HIV patient support groups, for the development and implementation of a joint national plan with HIV surveillance among TB patients irrespective of HIV prevalence rates.

Doctors with Africa CUAMM’s approach to the development of health systems and services has always been in partnership with local authorities and in line with national programs. In some countries such as Angola and South Sudan, Doctors with Africa CUAMM has been engaged in a dialogue with the National Tuberculosis Program at central level. However the main actions regarding this point of the Stop TB strategy is usually done at hospital level seeking real coordination of TB and HIV services. At other levels of the health system Doctors with Africa CUAMM will adopt the model of collaboration concentrating its effort at district, primary care service and community levels.

Reducing the burden of TB in people living with HIV/AIDS (PLWHA), through the intensification of TB case-finding among HIV/ AIDS patients with a referral system between

People, communities and health services: together for Tuberculosis care and control in Africa

9. WHO global tuberculosis control – surveillance planning financing, WHO report 2008.

10. The global paln to stop tb 2011 – 2015, WHO 2011.

11. Health and development, tb control in angola, September 2011 n.61 12. WHO Three I’s Meeting Intensified Case Finding (ICF), Isoniazid Preventive Therapy (IPT) and TB Infection Control (IC) for people living with HIV report of a Joint World Health Organization HIV/aids and TB department, April, 2008, Geneva, Switzerland

HIV and TB services, the provision of isoniazid preventive therapy as part of PLWHA care when TB is excluded.

WHO recommends that all people who test positive for HIV and are also found to have TB should start TB treatment immediately.

After two weeks on TB treatment, they should begin ART13. HIV testing of TB patients is now standard practice in many countries, especially in the African Region, however further efforts are needed to achieve similar results at global level.14 The introduction of a new test with high sensitivity and specificity, the Xpert MTB/RIF, can lead to an improvement in TB care and control.15 At all levels (hospital, centers and health post) where Doctors with Africa CUAMM is providing HIV care or treatment, the management of HIV+ patients will include TB screening and testing, and isoniazide preventive therapy will be ensured in line with national guidelines. This will be achieved by providing capacity-building

to local managers and training of health professionals. WHO algorithm for intensified screening and testing will be adopted. The introduction of the Xpert MTB/RIF test will also be introduced giving priority to settings with high HIV prevalence.

This commitment is taken considering that 4 out 7 countries where Doctors with Africa CUAMM works have the highest number of deaths for HIV associated with TB. Reducing the burden of HIV in patients living with TB, through HIV testing and counseling for all TB patients when HIV prevalence among TB patients exceeds 5%, the provision of HIV prevention services and cotrimoxazole preventive therapy to TB patients with HIV infection, also provision of antiretroviral therapy to TB patients with HIV infection, and provision of care and support services to TB patients with HIV infection.

Evidence from observational studies shows that testing of HIV patients with presumptive

figure 2

49 000 | 245 000 Deaths from HIV-associated TB per year

Projected deaths from HIV-associated TB between 2011-2015 given current levels of care

India

40 000 | 200 000

Nigeria

Ethiopia

49 000 | 245 000

14 000 | 70 000

Uganda

Kenya

19 000 | 95 000

Tanzania

14 000 | 70 000

11 000 | 55 000

Mozambique

Zambia

11 000 | 55 000

22 000 | 110 000

Zimbabwe

27 000 | 135 000

South Africa

83 000 | 415 000

This is a stylized map; it is not an official map of WHO or UNAIDS.

13. Time to act Save a million lives by 2015 - Prevent and treat tuberculosis among people living with HIV, WHO stop TB department 2011.

14. WHO global tb report 2011.

15. Boheme et al, Feasibility, diagnostic accuracy, and effectiveness of decentralized use of the Xpert MTB/RIF test for diagnosis of tuberculosis and multidrug resistance: a multicentre implementation study, Lancet 2011; 377: 1495â&#x20AC;&#x201C;1505.

or diagnosed TB yields a high number of new diagnoses of HIV infection, as prevalence of HIV is higher than among the general adult population.16 The WHO 2011 global tuberculosis report shows that when 59% of patients with TB are tested for HIV, about 44% of them were found to be HIV-positive in sub-Saharan Africa.17 Cotrimoxazole is a simple, well-tolerated and cost-effective intervention associated with a 25–46% reduction in mortality among individuals infected with HIV in sub-Saharan Africa.18 However implementation of WHO protocols is often hampered by erratic supply and lack of stocks (“stock-outs”), insufficient health-care worker awareness because of lack of training and supervision, and lack of integration of TB/HIV programming.19 Doctors with Africa CUAMM is promoting HIV testing to all patients with presumptive or diagnosed TB following the WHO recommended algorithm and guidelines.

Doctors with Africa CUAMM objective is to guarantee that more than 80% of TB patients are counselled and tested for HIV, Co-trimoxazole preventive therapy will be provided, enhancing TB/HIV program integration, providing capacity building to local managers and training of health professionals.

Prevent and control multidrug-resistant TB Multidrug resistant (MDR-TB) and extensively drug-resistant TB (XDR-TB) are major threats to TB care and control, with all countries at risk.

MDR-TB is defined as resistance to, at least, isoniazide and rifampicin, XDR-TB is defined as MDR-TB plus resistance to at least, any fluoroquinolone and any of the three secondline injectable drugs.

Prevention of resistance relies on early case finding and effective treatment through DOTS and other Stop TB strategies;20 prevention programs should also take into consideration a wide set of infection control measures at healthcare facilities to avoid the propagation of the MDR epidemic21. Furthermore the introduction of new diagnostic tests at peripheral level may change the role of the local laboratories and health facilities.22 As many of the TB control units supported by Doctors with Africa CUAMM are not able to provide MDR services due to their “rural” and peripheral sites, great effort will be given to: • prevention of MDR through proper first line 8— 9

TB treatment and follow up and infection control measures.

• Expansion of Xpert MTB/RIF. • Establishment of referral systems where culture and DST are available.

• Referral of MDR suspected cases for appropriate diagnosis and treatment.

Active collaboration with National Tuberculosis Program will be ensure to guarantee the above mentioned point, especially for the concern of ensuring an well working referral system for culture and DST in MDR suspected cases and second line treatment to MDR confirmed cases.

Address prisoners, refugees and other high-risk groups and special situations Vulnerable groups such as the homeless, the unemployed, migrants, alcohol-dependent people and ex-prisoners are more prone to TB infection than the general population.

Prisoners are exposed to TB and especially MDR-TB, which spreads easily as a result of overcrowding, inadequate ventilation, malnutrition and poor hygiene. In some countries, the incidence of TB has been recorded approximately 50 times higher, and the mortality rate approximately 28 times higher 23, among prisoners than among the civilian population.

Special situations will be addressed on the basis of local assessments promoting publicprivate mix (PPM) where appropriate.

Special needs in particular population groups will be identified during district population surveys and interventions will be planned in harmony with local and national plans.

Collaboration with National Tuberculosis Program (NTP) will be a key factors in the identification of special situation and the planning of appropriate interventions or integration with existing services.

3. Contribute to health system strengthening a- Actively participate in efforts to improve system-wide policy, human resources, financing, management, service delivery and information systems Doctors with Africa CUAMM activities, in support of district health systems and training, is focused on the four main components of health systems namely, governance, management, equitable financing, and technical knowhow24. The approach on TB control will follow the same

People, communities and health services: together for Tuberculosis care and control in Africa

16. WHO, WHO policy on collaborative TB/HIV activities Guidelines for National programmes and other stakeholders, WHO 2012.

17. WHO, global tuberculosis report, stop tb 2011.

18. Date et al, Implementation of co-trimoxazole prophylaxis and isoniazid preventive therapy for people living with HIV Bulletin of the World Health Organization 2010;88:253-259. doi: 10.2471/BLT.09.066522.

19. Guidelines on cotrimoxazole prophylaxis for HIV infections among children, adolescents and adults in resource-limited settings: recommendations for a public health approach. Geneva: World Health Organization; 2006.

20. Raviglione MC, uplekar MW. WHO’s new stop tb strategy.

Lancet 2006; 367: 952-55.

21. WHO, WHO policy on TB infection control in health-care facilities, congregate settings and households. WHO 2009.

22. Gandhi et al, multidrugresistance and extensively drugresistance tuberculosis: a threat to global control of tuberculosis, the lancet series – tuberculosis may 2010.

23. World health organization, stop tb department, working group for DOT expansion strategic plan 2006 – 2015.

24. Doctors with Africa CUAMM, strategic paln 2008 – 2015.

outline also integrating activities into a wider public health agenda. Guaranteed access to essential health services including, for example, MCH, HIV and TB care is possible only through Universal Health Coverage. Doctors with Africa CUAMM will vigorously advocate and help countries in Africa to progress towards Universal Health Coverage. b- Share innovations that strengthen systems, including the Practical Approach to Lung Health Adapt innovations from other fields Innovation in approaches, technologies or strategies will be studied in various fields from maternal and neonatal death, HIV, neglected diseases etc.

Mobile phone technology, introduction of digital X-ray, geographical information system for the mapping of epidemics and statistics are already in the pipeline for testing in Doctors with Africa CUAMM’s projects. PAL approach will be taken into account in all the health facilities supported.

4. Engage all care providers Public–Public and Public–Private Mix (PPM) approaches Evidence suggests that failure to involve all care providers used by TB suspects and patients hampers case detection, delays diagnosis, causes improper diagnosis as well as inappropriate and incomplete treatment, increases drug resistance and places a large and unnecessary financial burden on patients.

PPM can cost effectively increase case detection and notification to National Tuberculosis Program (NTP)25 - 26 increasing equity in access to care by engaging providers who are the primary agents for poor people seeking health care27 in some cases saving people from catastrophic expenditure for health.28 Doctors with Africa CUAMM strongly believes that all its interventions in TB control must be coordinated with the NTP program at the relevant level5 (central, regional or district).

Our community activities must be coordinated with NTP and Primary Health Care programs seeking integration and collaboration, including PPM activities when available.

Furthermore, Doctors with Africa CUAMM mainly works in PNFP hospitals and health

units.Those must be fully recognized and coordinated with the NTP at local, regional or district level in order to be identified as a diagnostic and DOTS provider with a full mandate for case management and follow up.

International Standards for Tuberculosis Care The purpose of the International Standards for Tuberculosis Care (ISTC) is to describe a widely accepted level of care that all practitioners, public and private, should seek to achieve in managing patients who have, or are suspected of having tuberculosis.29 Since Doctors with Africa CUAMM is committed in providing appropriate and standardized TB care, the ISTC will be used as a guide in all hospital and health units supported, promoting regular quality assessments and training of local staff on these standards.

5. Empower people with TB and communities Advocacy, Communication and Social Mobilization (ACSM) In the context of wide-ranging partnerships, ACSM embraces: Advocacy to influence policy changes and sustain political and financial commitment, two way Communications between care providers and people with TB as well as communities and Social Mobilization to engage the society itself.

Inadequate funding and lack of political will has slowed both the development of appropriate TB control policies and their successful implementation at the central, district and local levels. Even when good TB policies exist, there is often a gap between the policies and the program being implemented. Experience suggests that TB control services are negatively affected if there is no strong commitment from particular sectors of society, such as decision-makers, influential political and community leaders.

In addition to this public stigma is often the reason people with TB do not seek diagnosis or care. Improved public education and awarenessraising initiatives about what causes TB, how it is transmitted and whether it can be cured can help to mitigate the stigma not only among health-care workers, but also among the general public.19 - 20 Doctors with Africa CUAMM will leverage its long collaboration with National authorities

25. Lönnroth K, Uplekar M, Blanc L. Hard gains through soft contracts - productive engagement of private providers in tuberculosis control. BullWHO 2006; 84: 876-83.

26. Sinanovic E, Kumaranayake L. Financing and costeffectiveness analysis of publicprivate partnerships: provision of tuberculosis treatment in South Africa. Cost Eff Resour Alloc.

2006 Jun 6;4:11.

27. Rasmus Malmborg, Gillian Mann and S B Squire; A systematic assessment of the concept and practice of publicprivate mix for tuberculosis care and control; International Journal for Equity in Health 2011.

28. A Pantoja, K Floyd, K P Unnikrishnan, R Jitendra, M R Padma et al Economic evaluation of public-private mix for tuberculosis care and control, India. Part I. Socio-economic profile and costs among tuberculosis patients. The international journal of tuberculosis and lung disease the official journal of the International Union against Tuberculosis and Lung Disease (2009); Volume: 13, Issue: 6, Pages: 698-704.

29. http://www.who.int/tb/ publications/2006/istc_report. pdf

in order to advocate and influence policy changes and to maintain strong political and financial commitment. Doctors with Africa CUAMM will use its role of a care provider to enhance the communication between the care providers and people with TB patients, as well as communities to improve knowledge of TB control policies, programs and services in order to make health services more responsive to community needs. Finally, CUAMM will use its influence both at national and community level to enhance social mobilization and to engage society, especially the poor, and all partners of the campaign to Stop TB. Community participation in TB care Creating a working partnership between the health sector and the community ensuring that patients and communities alike are informed about TB, enhancing general awareness about the disease and sharing responsibility for TB care can lead to effective patient empowerment and community participation, to increase the demand for health services and to bring care closer to the community.

The need to promote the communities contribution to TB care as part of NTP activities is particularly urgent in sub-Saharan Africa, where HIV is fuelling the TB epidemic and the increased TB cases are outstripping the ability of government health service providers to cope.

With reliance often only on government health service providers, very few NTPs in high HIV prevalence countries are achieving adequate TB case detection rates and treatment outcomes.

The two principal outcomes of community programs are: treatment adherence and case finding. Treatment outcomes among patients cared for in the community were either equivalent to or (more frequently) improved, compared with patients treated through health facilities. Treatment success rates often reached the global target of 85% (taking into account the frequently high TB case fatality in high HIV prevalence populations). Costs associated with community-based DOTS were typically 40-50% lower than health facility-based care, and costeffectiveness of community-based DOTS was approximately 50% higher.20 Doctors with Africa CUAMM will promote the participation of TB patients and communities in TB care in order to allow people with TB to be identified and diagnosed more quickly, especially among vulnerable groups who do not have easy access to TB services.

10â&#x20AC;&#x201D; 11

The focus of Doctors with Africa CUAMM community program will be the introduction of community-based DOTS, support and motivation of patients to adhere to therapy, general support (included psychological support to face the social stigma), increased community awareness and education to reduce the stigma, and improve case finding and to ensure access to health facilities and treatment.

6. Enable and promote research The Stop TB Strategy consolidates DOTS implementation and involves the implementation of several new approaches for tackling the challenges facing NTPs. In order to put these approaches into practice, programme-based operational research should be a core component of NTP work. Designing and conducting locally relevant operational research can help to identify problems and workable solutions, testing them in the field and planning for their scale up of activities.

Tuberculosis remains a major global health threat also due to the complex interaction of factor that sustain the epidemic globally; for this reason, the tuberculosis research agenda is important and urgent30. Despite huge challenges in the research of new diagnostics, drugs and eventually a vaccine, programmatic research can relay of a standard set of indicators and a monitoring and a evaluation system that is implemented world wide31. The Stop TB strategy identifies two main areas for research: a- Conduct programme-based operational research Operational research as a means to identify â&#x20AC;&#x153;what works and what does notâ&#x20AC;? and implement cost efficient, sustainable interventions that are responding to the needs of local population is one of the priority identify in Doctors with Africa CUAMM Strategic Plan, Operational research must use international standard tools and methods for appropriateness, quality of the research design, data collection and ethical approval of any internal or external assessment.

The results of the operational research should be disseminated both inside and outside Doctors with Africa CUAMM and, first of all, should be taken into consideration by project and country managers in the

People, communities and health services: together for Tuberculosis care and control in Africa

30. Prof Ben J Marais et al, Scale-up of services and research priorities for diagnosis, management, and control of tuberculosis: a call to action.

The Lancet, Volume 375, Issue 9732, Pages 2179 - 2191, 19 June 2010 31. Raviglione et al, sustainable agenda for Tb control and reserch, The Lancet, Volume 379, Issue 9821, Pages 1077 1078, 24 March 2012

management of their interventions and in the writing / presentation of new interventions.

In order to ensure the points above, it is necessary to work in partnership with those institutions who are internationally recognised in research and to adopt the latest research tools created.

As example the TB control reaserch the reaserch agenda will include: • Childhood tb, diagnostics, treatment and outcomes Integration of tb services with HIV and mnch services.

• Introduction and impact on treatment outcomes of the xpert mob/rif • diagnostic test.

• •

Diagnostic delay of tb and its association to socio-economic determinant Tb control in urban areas

b- Advocate for and participate in research to develop new diagnostics, drugs and vaccines

Advocacy for new diagnostic, drugs and vaccines is not a priority for Doctors with Africa CUAMM. However, implementation and operational research of innovative diagnostic such as the Xpert TB/RIF machine or the use of Urine test for the detection of TB has been taken into consideration, especially for vulnerable risk groups such us children, HIV+ people and pregnant women.

Doctors with Africa CUAMM via San Francesco, 126 35121 Padova - Itay t. 049 8751279 f. 048 8754738 cuamm@cuamm.org www.doctorswithafrica.org c/c postale 17101353 Photo credits: copertine/covers: Archivio CUAMM/ CUAMM Archive Design: Heads Collective Stampa: Publistampa

12— 13

Authors: • Atzori Andrea, delegate for International Relations, Doctors with Africa CUAMM, Padova - Italy • Besozzi Giorgio, direttore Centro di Formazione TB, Istituto Villa Marelli, Milan - Italy • Cirillo Daniela Maria, Head of SRL-EBPU, San Raffaele Scientific Institute, Milan - Italy • Codecasa Luigi R., responsabile Centro regionale di Riferimento per la Tubercolosi Istituto Villa Marelli Az. Osp. Niguarda Ca’ Granda, Milan Italy

• Gargioni Giuliano, Team Leader National and Global Partnerships, Stop TB Partnership Secretariat World Health Organization WHO/STB/TBP, Geneva 27 - Switzerland • Inojosa Walter, dirigente medico, UO Malattie Infettive, Ospedale di Treviso - Italy • Manenti Fabio, head of Project Department, Doctors with Africa CUAMM, Padova - Italy • Manfrin Vinicio, Infectious Diseases Specialist, Infectious and Tropical Diseases Unit. Saint Bortolo Hospital, Vicenza - Italy

• Matteelli Alberto, M.D., co-director, WHO Collaborating Centre for TB/HIV activities, Institute of Infectious Diseases, University of Brescia, Brescia, Italy • Migliori GB., Directors, WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri, Tradate, Italy • Putoto Giovanni, head of Planning, Doctors with Africa CUAMM, Padova - Italy • Raviglione Mario C., Director Stop TB Department (STB), World Health Organization, Geneva - Switzerland

People, communities and health services: together for Tuberculosis care and control in Africa

• Segafredo Giulia, PharmD, PhD student Epidemiology and Biostatistics and CUAMM external volunteer consultant, Padova - Italy • Tagliaferri Enrico, U.O.C. Malattie Infettive, Azienda Ospedaliera Universitaria Pisana - Italy Informations: a.atzori@cuamm.org

Padova, ottobre 2012

DOCTORS WITH AFRICA

Doctors with Africa CUAMM via San Francesco, 126 - 35121 Padova - Italy - tel 049 8751279

www.doctorswithafrica.org cuamm@cuamm.org c/c postale 17101353