Dr. Lucica Ditiu, Executive Director of the StopTB Partnership, shares her priorities for greater private sector action on the Global Plan to End TB: The Paradigm Shift (2016-2020) — a 5-year investment plan to accelerate elimination of TB and reach the targets of the WHO End TB Strategy.

1. The new Global Plan to End TB launched this year is called “The Paradigm Shift.” What are the key shifts that need to occur to ensure progress over the next five years?

“The Paradigm Shift” means CHANGE. The Global Plan to End TB highlights the need for change in the approach to more impactful action. It strongly underlines that the End TB milestones will be missed if current efforts continue without a paradigm shift.

The Global Plan calls for paradigm shifts. The most important ones that need to occur in the next couple of years are:

• Promoting political & social will through changes in mindset. More inclusive political leadership is needed to mobilize the government more broadly (from Presidents, Ministries of social protection, justice, education, labor to business sector and affected communities).
• Human rights-based approach & community-driven approach. A shift toward making decision-making processes more inclusive, protecting the privacy of people with TB and countering discrimination. People with TB and their communities must be partners in the design and planning of strategies, and given a key role in monitoring and evaluation – especially at the point of need.
• Modernizing TB programs will require programs to look for innovative approaches, embracing the use of new ideas and tools to allow leapfrogging. It will also require the use of information technology, social media, e- and m-health and other new approaches for collecting actionable programmatic data.
• Developing new approaches to fund TB care by engaging the business sector and private-sector health providers as important partners, harnessing companies’ consumer-led approach and accepting the sector’s ability to generate revenue through social business models. As social health insurance initiatives and innovative financing mechanisms scale up, TB programs need to proactively align and integrate into these initiatives.

The Global Plan also calls for countries to meet the 90-(90)-90 targets by 2020, or 2025 at the latest. If countries can focus on high-impact interventions and reach these targets, the world will see an incidence decrease unlike before.

• Reach at least 90% of all people with TB and place all of them on appropriate therapy – first line, second line and preventive therapy as required.
• As a part of this approach, reach at least 90% of the key populations – the most vulnerable, underserved, at-risk populations.
• Achieve at least 90% treatment success for all people diagnosed with TB through affordable treatment services, adherence to complete and correct treatment, and social support.

 

2. What is the Partnership focusing its energy on this World TB Day?

Now with the opportunity before us to put an end to the world’s leading infectious killer – TB – we must respond with ambition and resources. This year, in line with the paradigm shift called for by the Global Plan to End TB 2016-2020, we wanted to make sure that we got a good head start and that we do things differently.

The theme this year was “Unite to End”, and more than in any other year, we are uniting activists, politicians, and people affected by TB around the world in solidarity. For far too long, TB was not on the radar of policymakers. Today, we have the largest parliamentary group ever created for a health issue, with parliamentarians from over 100 countries pledging to join the fight to end TB through the Global TB Caucus.

In the past, the TB community’s focus was on managing and controlling TB. Today we have expanded our ambition to ending TB. We have a globally endorsed strategy, and a roadmap through the Stop TB Partnership’s Global Plan to End TB 2016-2020, which includes the 90-(90)-90 targets.

Among World TB Day activities held this year:

• In Washington D.C., we were part of a high-level World TB Day event hosted by USAID that united global and US leaders to End TB. Over 400 people attended the event where USAID presented the TB Champion Award to Dr. Aaron Motsoaledi, Minister of Health of South Africa and Chair of the Stop TB Partnership board, in recognition of his leadership and achievements for fighting TB in South Africa.

• In an unprecedented World TB Day event held in New Delhi, the Indian government and Ministry of Health and Family Welfare launched a series of initiatives and new tools aimed at fast-tracking scale-up of quality diagnosis and treatment in order to rapidly decrease the TB burden.The event saw the release of WHO’s Regional Strategic Plan 2016-2020, the Annual TB Report of India, as well as important technical and operational guidelines for TB care in India. In addition, the government of India launched several new tools such as the new anti TB drug bedaquiline, 500 new Gene Xpert machines and third-line anti-retroviral therapy, as well as a media campaign for awareness-raising in the general population.The event was jointly organized by India’s Ministry of Health and Family Welfare and WHO’s Regional Office for South-East Asia, along with other partners including the Stop TB Partnership, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and USAID.

 

3. According to a recent report prepared by the Global Fund Secretariat, there is limited recognition of the gravity of the MDR-TB problem in many countries. What can we do to accelerate knowledge and understanding around the challenges associated with MDR-TB?

Right now, MDR-TB is a very big issue. And unfortunately due to the fact that we are unable to diagnose and treat a large portion of the cases, a big number of people remain undiagnosed. Undiagnosed and untreated cases are easily spread through the air, meaning MDR-TB is an always-growing problem. At some level, Ministries of Health are aware of these issues, but what we really need is a sense of urgency. All TB programs in the world are aware that MDR-TB is a problem, but they really need to realize just how bad it is, what the financial impact will be of leaving cases untreated, and prioritize MDR-TB with funding and action.

We have an End-TB Strategy with the World Health Organization (WHO) and a comprehensive package of programs outlining what we should do in the next five years. The first step is identifying everyone with MDR-TB and getting them on treatment with the aim of curing them. We need to make sure we are pushing forward dedicated funding and the inclusion of MDR-TB patients in existing TB programs.

We also need guidelines in place for diagnosing MDR-TB cases. Gene Xpert is pretty good at being able to diagnose rifampin resistance, but it is not widely used due to its high cost. Clinicians are primarily using microscopy to diagnose TB, and then only using Gene Xpert after the fact.

Drug resistant treatments are not easy. They are time-consuming, have numerous side effects and are extremely expensive. Bedaquiline is being offered freely through the GDF, alongside other drugs that are subsidized, but scale-up has been difficult because we do not put people at the core of our interventions. Lack of funding also makes governments reluctant to treat MDR-TB.

There are four key things that the global TB community can do to accelerate the country-level management of MDR-TB: partake in advocacy at the country-level, provide appropriate technical assistance utilizing in-country experts, meaningfully engage with the people affected by TB, and support the roll-out of new treatments and diagnostics to ensure their uptake and inclusion in guidelines.

Finally, we need to make sure that when we leave, there are experts remaining. We need to construct and invest in strengthening communities. Bringing together primary health care systems and community health workers with networks of affected people will empower communities to work hand in hand to end TB.

 

4. What are the key gaps and challenges concerning gender in TB and how will implementation of the newly developed HIV/TB Gender Assessment Tool help address these gaps?

It is well-known that TB prevalence is higher among men than women, but gender issues go beyond the mere prevalence of disease.

Women experience more barriers to access to effective diagnosis and treatment. For example, it is more common for women to have extrapulmonary TB which is more difficult to diagnose. Women tend to go to smaller health facilities where there is access to only smear microscopy and not more advanced screening equipment like Gene Xpert and x-rays. Culturally, it is also difficult for women to provide a sputum sample in an open collection area or for screening to occur with a male health care worker present.

Men, women, children and the elderly also face different challenges in accessing care, have different treatment seeking practices, face different levels and different types of stigma and discrimination, and the social impact of the disease is different. A gender sensitive program needs to be sensitive to this and the response should address all issues related to gender.

Most important is the lack of disaggregated data to inform gender transformative interventions. We must get the TB community to collect this data and use it to inform programming.

The TB/HIV Gender Assessment Tool will enable countries to get a baseline of their gender responses and provide them with an opportunity to find the gaps and implement innovative interventions to address them.