Planning and DOTS implementation
All HBCs have a strategic plan for DOTS expansion and, during 2005, many will begin a new planning cycle for the next five years. However, the transition from planning to implementation, and then to the improvement of coverage, case detection and treatment success has been slower than anticipated in several countries. The success of some NTPs in raising funds for TB control (and particularly from the GFATM) has not been followed by productive spending.
Among the obstacles to DOTS expansion, five are of overriding importance: shortages of trained staff, lack of political commitment, weak laboratory services, and the inadequate management of MDR-TB and of TB in people infected with HIV.
The acute shortage of adequately trained staff affects the distribution and quality of services. This workforce crisis is felt particularly in the under-performance of central management, and through failings in the laboratory network. To remedy the problem, the HBCs need, at the very least, strong and clear policies for recruiting, retaining and motivating staff. One way to secure political commitment to solve this and other problems is by strengthening national and international partnerships. A consistent message about the importance of TB control, delivered from various constituencies, is a basis for effective advocacy and com-munication.
Besides the staff shortages, many laboratories participating in DOTS programmes have insufficient equipment and supplies, and limited procedures for quality assurance. All these essential elements need to be in place before laboratories take on the larger tasks of culturing M. tuberculosis and testing for drug sensitivity, as will be required to integrate DOTS-Plus projects within DOTS programmes. To help improve capacity in HBCs, the DEWG has established a subgroup concerned with laboratory strengthening.
In addition to the deficiencies in laboratories, the lack of national policies on MDR-TB management, the widespread availability of drugs of uncertain quality and the large numbers of MDR-TB patients treated outside the NTP together suggest that the treatment of drug-resistant TB is often inadequate. The high proportions of re-treatment cases reported by NTPs are also a signal that drug-resistant forms of TB could be common in some populations where no surveys have yet been done. There are several remedies. WHO is in the process of expanding drug resistance surveillance and DOTS-Plus components within the context of regular TB control programmes. WHO is also working to establish a long-term competitive market for quality-assured drugs by leading a project to pre-qualify second-line drugs worldwide. GFATM grants are also being used to stimulate demand for drugs from reliable manufacturers. The Fund has selected the GLC as the mechanism for second-line drug procurement, and for monitoring approved projects.
The management of drug-resistant TB will be aided by a better understanding of the scale and distribution of the problem. Surveillance of drug resistance must be expanded to the five HBCs for which no data are yet available,8 and to other countries suspected to have high prevalence rates of MDR-TB. Information about new TB patients will be supplemented by data on patients presenting for re-treatment, including the systematic notification of all categories of re-treatment cases, the reporting of treatment outcomes and representative drug resistance surveys.
During 2003, very few TB patients had access to VCT and to ART. The numbers that actually have access to these services are probably somewhat higher than reported, but cannot be accurately known until TB/HIV monitoring systems are substantially improved. HIV/AIDS programme staff are increasingly aware of the fact that people infected with HIV are at high risk of developing active TB, while their counterparts in TB control programmes are seeing the impact of HIV on TB case-load, and on death rates in cohorts of TB patients on treatment. There has, until now, been little collaboration between TB and HIV/AIDS control programmes, but many such programmes are beginning to adopt elements of the WHO interim policy on collaborative TB/HIV activities.15 Even with the imperfect data presented in this report, it is clear that much closer collaborations of this kind are needed to develop and improve access to prevention, treatment and support services, for both TB and HIV/AIDS patients.
Notwithstanding these weaknesses, this report has also identified a series of positive developments in DOTS implementation. The contributions to TB control of NGOs and community groups are clear expressions of the growing commitment of civil society. The work of these groups puts patients at the centre of the DOTS strategy, and improves access to TB services in remote areas and among disadvantaged and marginalized populations. NGOs are increasingly recognized as essential members of national partnerships for TB control. This recognition is helping not only to coordinate routine activities but also to develop a collaborative approach to solving the problems faced by NTPs. Some African countries are planning to involve community groups in collaborative TB/HIV activities. PPM projects are showing a measurable impact on case detection in several Asian countries, and may prove to be a mechanism for expanding TB control services in African cities.
With the significant influx of resources for TB control (from the GFATM, banks and bilaterals), especially to HBCs, some additional, catalytic funding is needed to ensure that NTPs have the technical capacity to make the best use of the new grants and loans. To satisfy this need, Stop TB partners launched a new initiative in 2003 – ISAC – an extraordinary effort to push towards the 2005 targets in selected countries, including China, India and Indonesia. The technical work under way aims to facilitate the access of patients to DOTS services, for example by expanding the geographical coverage of DOTS, by involving a greater diversity of public and private health-care providers, by strengthening in-country advocacy and social mobilization, and through partnership building and collaborative TB/HIV activities.