MODULE SIX Global TB Institutions and Policy Framework Treatment Action Group TB/HIV Advocacy Toolkit 1
Topics to be Covered Global TB policy and coordinating structures The Stop TB Strategy TB/HIV collaborative policy Advocacy priorities 2
Section 1: Global TB policy and coordinating structures 3
What are the major global TB policy The Stop TB Partnership & coordinating structures? The TB global response has two major players: -Network of international organizations, countries, public and private donors, governments, nongovernmental organizations and individuals working together to eliminate TB -Develops and publishes the Global Plan to Stop TB, which lays out the framework for the global TB response -Includes seven working groups as well as a coordinating board HIV, Working groups focus on implementation and new tools: diagnostics, TB/ MDR-TB, childhood TB, vaccines, the Global Laboratory Initiative and DOTS expansion The Stop TB Department of the WHO -Provides leadership in strategic and technical aspects of TB control worldwide, in order to reverse the epidemic and eventually eliminate TB -Responsible for developing all the TB-related policies that drive the global response to TB 4
The Stop TB Partnership vs. the Stop TB Department The Partnership is... a coalition of public and private stakeholders governed by a coordinating board made up of representatives from different constituencies headed by the executive secretary who is supervised by the WHO Stop TB Department director and is also accountable to the Partnership s coordinating board The WHO s Stop TB Dept is... A department within the WHO, a UN agency. governed by the 193 member states of the World Health Assembly headed by the Stop TB Department director who reports to the WHO s assistant director general for HIV/AIDS, TB, malaria, and neglected tropical diseases 5
The Stop TB Partnership vs. the Stop TB Department The Partnership... has established seven working groups that provide technical expertise on TB control and research; the secretariats of five of the working groups are housed at the WHO has developed the Global Plan to Stop TB which is an assessment of the action and resources needed to eliminate TB The WHO Stop TB Dept... relies on the recommendations of the Strategic Technical Advisory Group for TB (STAG-TB) to steer the development of WHO policies and guidance produces the annual Global Tuberculosis Report that tracks global and country progress toward TB elimination as well as all TBrelated health policies to guide the implementation of the Stop TB Strategy 6
Source: Stop TB Department, January 2012 7
Section 2: Global TB strategy 8
TB Control Targets The eight Millennium Development Goals (MDGs) form a blueprint agreed upon by world leaders and all the leading development institutions to meet the needs of the world s poorest. Global TB targets linked to the MDGs and endorsed by the Stop TB Partnership: by 2005: detect at least 70% of new sputum smear-positive TB cases and cure at least 85% of these cases by 2015: reduce TB prevalence and death rates by 50% relative to 1990 rates by 2050: eliminate TB as a public health problem The Stop TB Partnership s Global Plan to Stop TB: 2011 2015 also has targets that it aims to achieve by 2015, including: 6.9 million cases (per year) are diagnosed, notified, and treated according to DOTS 100% of previously treated TB patients are tested for MDR-TB >50% of smear-negative TB cases are screened using culture and/or molecular-based test $46.7 billion over five years to fund all components of the plan The UN General Assembly 2011 High Level Meeting on AIDS Reduce by 50% tuberculosis deaths in people living with HIV by 2015 9
The DOTS Strategy In 1991 the World Health Assembly recognized TB a global threat and called for a comprehensive response. In 1993, the WHO declared TB as an emergency. In 1994 the WHO launched the internationally recommended strategy (later named DOTS). The original strategy had five components: 1. Secure political commitment with adequate and sustained financing. 2. Ensure early case detection and diagnosis through quality-assured bacteriology. 3. Provide standardized treatment with supervision, and patient support. 4. Ensure effective drug supply and management. 5. Monitor and evaluate performance and impact. 10
Limitations of the 1994 DOTS Strategy Focused only on identification of smear-positive pulmonary TB cases because they are most infectious. Since 2009, the WHO has given less importance to achieving only 70% of smear-positive pulmonary TB and instead focused on universal access to treatment for all forms of TB. Relied on passive case finding, meaning persons with TB symptoms needed to come to the TB clinic to seek diagnosis, instead of programs going into the community to identify potential TB cases. In 2006, the DOTS strategy was updated to focus on early case detection in order to get people into care early and reduce transmission. Emphasized the importance of directly observed therapy (DOT) as a major method of ensuring adherence. The 2006 version of the Stop TB Strategy emphasized supervision and patient support to improve adherence, instead of only DOT. 11
The 2006 Stop TB Strategy The WHO along with partners, revised and expanded its TB control strategy to address the limitations the DOTS Strategy. The revised Stop TB Strategy was launched in 2006: VISION: A world free of TB. GOAL: To dramatically reduce the global burden of TB by 2015 in line with the MDGs and the Stop TB Partnership targets and to achieve major progress in the research and development needed to eliminate TB. 12
Objectives of the Stop TB Strategy To achieve universal access to TB treatment for all forms of TB. To reduce the suffering and socioeconomic burden associated with TB. To protect the poor and vulnerable populations from TB, TB/HIV and MDR TB. To support the development of new tools and enable their timely and effective use. 13
Components of the Strategy 1. Pursue high-quality DOTS expansion and enhancement. a) Political commitment with adequate and sustained financing. b) Ensure early case detection and diagnosis through quality assured bacteriology. c) Provide standardized treatment with supervision and patient support. d) Ensure effective drug supply and management system. e) Monitor and evaluate performance and impact. 14
Components of the Strategy 2. Address TB/HIV, MDR-TB, and the needs of the poor and vulnerable populations. a) Scale up collaborative TB/HIV activities. b) Scale up prevention and management of MDR-TB. c) Address the needs of TB contacts, and of poor and vulnerable populations. 15
Components of the Strategy 3. Contribute to health system strengthening. a) Help improve health policies, human resource development, financing, supplies, service delivery, and information. b) Strengthen infection control in health services, other congregate settings, and households. c) Upgrade laboratory networks, and implement the Practical Approach to Lung Health. d) Adapt successful approaches from other fields and sectors, and foster action on the social determinants of health. 4. Engage all care providers. a) Involve all public, voluntary, corporate and private providers through public-private mix approaches. b) Promote use of the International Standards for Tuberculosis Care. 16
Components of the Strategy 5. Empower people with TB and communities through partnerships. a) Pursue advocacy, communication, and social mobilization. b) Foster community participation in TB care, prevention, and health promotion. c) Promote use of the Patients' Charter for Tuberculosis Care. 6. Enable and Promote Research. a) Conduct program-based operational research. b) Advocate for and participate in research to develop new diagnostics, drugs and vaccines. 17
Section 3: The Interim Policy on Collaborative TB/HIV Activities 18
Overview: The WHO Interim Policy on Collaborative TB/HIV Activities The policy was published in 2004. The policy is in the process of being revised to take into account new data. It is expected to be reissued in March 2012, with additional recommendations to initiate early ART and collocate TB and HIV services. Rationale: Developed to assist policy makers in determining what should be done to address the joint burden of TB/HIV. Goal: To decrease the burden of TB and HIV in populations affected by both diseases. 19
Recommended Collaborative TB/HIV activities. A. Establish a mechanism for collaboration A1 Set up a coordinating body for TB/HIV activities effective at all levels A2 Conduct surveillance for HIV prevalence among tuberculosis patients A3 Carry out joint TB/HIV planning A4 Conducting monitoring and evaluation B. Decrease the burden of tuberculosis in people living with HIV/AIDS B1 Establish intensified case finding B2 Introduce isoniazid preventive therapy B3 Ensure tuberculosis infection control in health care and congregate settings C. Decrease the burden of HIV in tuberculosis patients C1 Produce HIV testing and counseling C2 Introduce HIV prevention methods C3 Introduce cotrimoxazole preventive therapy C4 Ensure HIV/AIDS care and support C5 Introduce antiretroviral therapy 20
What Are the Three I s? The Three I s are the elements of the policy under section B that are designed to decrease the burden of tuberculosis in people living with HIV/AIDS. The Three I s are primarily the responsibility of HIV programs. B1. Establish intensified case finding B2. Introduce isoniazid preventive therapy B3. Ensure tuberculosis infection control in health care and congregate settings 21
B1. Intensified Case Finding Screening for TB symptoms and signs. The 2004 Interim Policy states that evidence shows that intensified case finding prevents mortality interrupts TB transmission by identifying infectious cases decreases risk of nosocomial TB transmission offers the opportunity to provide TB preventive therapy to those who are HIV positive improves TB case detection and gets people with TB into appropriate treatment. 22
B2. Isoniazid Preventive Therapy (IPT) Information about IPT should be offered and IPT should be provided by HIV programs to HIV-positive people with latent TB infection. The 2004 Interim Policy states that evidence shows that Isoniazid is more effective and safer in preventing TB disease than regimens containing rifampin and pyrazinamide. IPT reduces the rate of TB incidence and death in people with HIV that have a positive tuberculin skin test (TST) the test used to identify latent TB infection. The feasibility of the TST test was less clear in developing countries, as IPT required steps to identify people with HIV and exclude active TB disease. In 2010 the WHO issued the Guidelines for Intensified Tuberculosis Case Finding and Isoniazid Preventive Therapy for People with HIV in Resource Constrained Settings to clarify how active TB can be ruled out and address common implementation concerns for IPT. 23
B3. Infection Control in Health Care and Congregate Settings Administrative measures early diagnosis and treatment separation of pulmonary TB suspects Environmental measures maximise natural ventilation ultraviolet irradiation Personal measures protection of people with HIV, including health care workers who are HIV positive IPT cough etiquette such as covering the mouth when coughing to prevent or reduce the spread of bacteria in the air. The 2009 WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households further clarifies activities that need to take place at the national and subnational levels, as well as in health facilites, congregate settings, and TB households. 24
Section 4: Advocacy Priorities 25
Advocacy priorities Ensuring that TB control efforts move to implement the full strategy and that there is adequate funding available for all components of the strategy. Preventing drug stockouts and shortages. Fully integrating MDR-TB, XDR-TB, and TB/HIV coinfection into the national TB response. Meaningful inclusion of the community and the provision of resources to strengthen response. TB clinical and operational research needs to be fully funded according to the Global Plan to Stop TB 2011 2015. Strong science- and policy-literate activists who are linked with local TB-affected communities to work at the global level. Community-based monitoring of global TB targets. 26
Module Review Name two institutions that play critical roles in the global TB response and why it is important to be aware of them. Name three differences between the Stop TB Partnership and the Stop TB Department. What are the six components of the Stop TB Strategy? What is the difference between DOT and DOTS? What is the MDG target that the global community has set for 2015? What are the three major categories of activities recommended by the 2004 Interim Policy on Collaborative TB/HIV Activities? What are the three major categories of activities recommended by the 2004 Interim Policy on Collaborative TB/HIV Activities? 27