TB and Poverty in The Global Plan to Stop TB 2006-2015 Valerie Diaz, Sarah England, Knut Lönnroth, Giorgio Roscigno Stop TB Partnership Stop TB Department,

TB and Poverty in

The Global Plan to Stop TB 2006-2015

Valerie Diaz, Sarah England, Knut Lönnroth, Giorgio Roscigno

Stop TB PartnershipStop TB Department, WHO

FIND

What is the Global Plan to Stop TB 2006-2015?

I. General strategic directions for Stop TB Partners for next decade, in relation to recent achievements and remaining challenges

II. Scenarios for implementation for 7 "epidemiological regions", including epidemiological and costing predictions

III. Summary of strategic plans of 7 Working Groups• DOTS Expansion, including Subgroups on TB/Poverty

PPM-DOTS, Lab Strengthening, and Childhood TB• DOTS Plus for MDR TB• TB/HIV• New TB Diagnostics• New TB Drugs • New TB Vaccines • Advocacy, Communications and Social Mobilization

……in line with WHO-recommended Stop TB strategy in line with WHO-recommended Stop TB strategy to reach the Stop TB Partnership's targets for 2015 to reach the Stop TB Partnership's targets for 2015

1. Pursuing quality DOTS expansion and enhancement• Political commitment • Case detection through bacteriology• Standardised treatment, with supervision and patient support• Effective drug supply system• Monitoring system and impact evaluation

Additional components:

2 Addressing TB/HIV and MDR-TB, and other challenges (prisoners, refugees, other risk groups)

3. Contributing to health system strengthening

4. Engaging all care providers (PPM DOTS)

5. Empowering patients and communities 6. Enabling and promoting research

Stop TB DepartmentStop TB Department

The targets for Global Plan

Process / outcome:• By 2005, and to be sustained or exceeded by 2015:

At least 70% of people with infectious TB will be diagnosed under the DOTS strategy and at least 85% of those diagnosed will be cured.

Epidemiological impact:• By 2015: TB prevalence and deaths will be reduced by

50% relative to 1990 levels. (MDG 6)

Summary of the global scenario for DOTS Expansion

• DOTS Expansion 2006-15 means:1. DOTS coverage (presence of a DOTS programme)

Improving quality and access:2. DOTS quality package (HR, microscopy, supervision, drug supply, IEC)3. Public Private Mix DOTS (PPM DOTS)4. Community DOTS5. Practical Approach to Lung health (PAL) 6. Culture and drug susceptibility testing (DST)7. Pro-poor strategy (part of all above)

• DOTS coverage: All countries by 2010

• DOTS quality package: All countries by 2015, treatment success ≥85% in all countries by 2015

Trend scenario for population to be covered by "new" DOTS Expansion approaches

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Qualityassuredculture andDST

DOTS-Plus expansion• Vision: Drug resistance surveillance and DOTS-Plus

integrated as routine components of TB control providing access to diagnosis and treatment for all TB patients and by all health care providers.

• 100% availability of culture and drug susceptibility testing by 2015

• By 2015: Treatment with quality-assured 2nd-line drugs to all detected MDR-TB patients following WHO guidelines

TB/HIV expansion

• Vision: TB/HIV collaborative activities scaled up in line with the UN target (endorsed by G8) of universal access by 2010 in all areas where HIV prevalence >1% in general adult population.

• Coordinate research to inform policy

• Increase political and resource commitment to collaborative TB/HIV activities

GP2: planned improvements in detection and treatment

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86% treatment success by 2015

81% case detection by 2015

TB deaths saved 2006-15 depend on DOTS 1996-2005

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By 2015, prevalence and death rates halved globally but not in Africa & E Europe

GP2: country needs, R&D and external agencies

R&D US$ 8.9 bn

External Agencies

US$ 2.8 bn

Country Needs

US$ 44 bn

Total needs GP2: US$ 55 bn

The Stop TB Partnership mission

• To ensure that every TB patient has access to effective diagnosis, treatment and cure;

• To stop transmission of TB;

• To reduce the inequitable social and economic toll of TB;

• To develop and implement new preventive, diagnostic and therapeutic tools and strategies to stop TB.

…and "Addressing poverty in TB control" is part of Global Plan:

• Step 1. Establish the profile of poor and vulnerable groups

• Step 2. Assess the barriers to accessing TB services faced by the poor and vulnerable

• Step 3. Take action to overcome barriers to access.

• Step 4. Work with situations and population groups requiring special consideration

• Step 5. Harness resources for pro-poor TB services

• Step 6. Assess the pro-poor performance of TB control and the impact of pro-poor measures

…but, the equity dimension is not yet reflected in the targets:

• By 2005, and to be sustained or exceeded by 2015: At least 70% of people with infectious TB will be diagnosed under the DOTS strategy and at least 85% of those diagnosed will be cured.

• By 2015: TB prevalence and deaths will be reduced by 50% relative to 1990 levels.

• No specific target related to equity in access or financial protection ! Do we need that?

Poverty / equity in the strategic plans of the

Implementing Working Groups

DOTS Expansion WG (DEWG)

DOTS Plus for MDR TB WG

TB / HIV WG

Advocacy,Communication, Social Mobilisation WG (ACSM)

DEWG framework linking activities to outcomes and MDGs

Planned activities1. DOTS coverage

2. DOTS quality package: -HR strategy -Supervision -Quality microscopy -Drug management -IEC

3. PPM DOTS

4. Community DOTS

5. PAL

6. Culture and DST

7. Pro-poor strategy

Improve TB management

Improve diagnostic qualityImprove case management Improve referral routinesImprove recording and reporting

TB control outcomes

Increase case detectionImprove treatment success rate

Equity outcomes

Reach all patients, especially the poorDecrease diagnostic delayReduce patients' direct and indirect costs

MDG6TB control impact

Reduce TB incidence

Halve TB prevalence Halve TB death rate

MDG1Poverty impact

Halve poverty and hunger

Reduce poverty and hunger among people

with TB and their families

Inputs Process Outcome Impact

Adapt services to the poor

Involve communitiesInvolve providers that serve the poor Provide free servicesReduce unnecessary testsDecentralize DOT

Pro

-po

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stra

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ies

Planned activities1. DOTS coverage

2. DOTS quality package: -HR strategy -Supervision -Quality microscopy -Drug management -IEC

3. PPM DOTS

4. Community DOTS

5. PAL

6. Culture and DST

7. Pro-poor strategy

Improve TB management

Improve diagnostic qualityImprove case management Improve referral routinesImprove recording and reporting

TB control outcomes

Increase case detectionImprove treatment success rate

Equity outcomes

Reach all patients, especially the poorDecrease diagnostic delayReduce patients' direct and indirect costs

MDG6TB control impact

Reduce TB incidence

Halve TB prevalence Halve TB death rate

MDG1Poverty impact

Halve poverty and hunger

Reduce poverty and hunger among people

with TB and their families

Inputs Process Outcome Impact

Adapt services to the poor

Involve communitiesInvolve providers that serve the poor Provide free servicesReduce unnecessary testsDecentralize DOT

No uniform indicators. No standard methods. No targets

Pro

-po

or

stra

teg

ies

DEWG framework linking activities to outcomes and MDGs

DOTS Plus equity framework• The DOTS-Plus for MDR-TB strategic plan, 2006-2015,

does not include explicit measures for reaching the poor and marginalized groups

• MDR-TB often hits poor people and marginalized groups

• WHO and the Green Light Committee strive to reach poor people and vulnerable groups through:– Urging NTPs to include all patients in the MDR-TB project

(homeless, alcoholics, prisoners etc.)

– Urging NTPs to provide incentives and enablers such as food, emotional support, and education of patients, family and peers on MDR-TB treatment

– Encourage NTPs to provide social and emotional support to patients and their families

TB HIV WG equity framework

• "Ensure that TB/HIV services are appropriate, accessible, acceptable and affordable to populations not specifically covered in existing policy, including women, children, mobile or remote populations, the poor, intravenous drug users and prisoners"

• "Monitoring and evaluation should demonstrate whether services are accessible and responding to the needs of the poor, women and marginalized groups."

ACSM framework

The poor lack:•Food security

•Income stability •Access to health care

•Adequate housing

Income poverty TB disease

TB may lead to:•Loss of 20-30% of annual wages among poor•Global economic costs: $12 billion annually

•Increased Social stigma

Stigma enhances the effects of poverty

Role for ACSM to break the cycle

Questions

• How to refine pro-poor strategies outlined in Global Plan and translate them into action?

• What is the evidence base concerning the extent to which current implementation (DOTS, DOTS Plus, TB/HIV) and new approaches (such as Community DOTS and PPM DOTS) are effective in reaching the poor?

• What indicators, targets and methods are needed to monitor equity in access and financial protection?

New tools WGs

New TB Diagnostics

New TB Drugs

New TB Vaccines

2005 2010 2015

Vaccines5 candidates in phase I trials

9 candidates in phase II trials. By 2008, at least 2 vaccines in phase IIb or 'proof of concept' trials. Start of phase III trials.

4 phase III efficacy trials carried out. 20 vaccine candidates entering phase I trials over plan period. One safe, effective, licensed vaccine.

Drugs27 new compounds in TB pipeline

1-2 new drugs registered for TB indication; treatment shortened to 3-4 months

7 new drugs registered for TB indication; regimen revolutionized; treatment shortened to 1-2 months

DiagnosticsRapid culture for case detection and DST in demonstration phase.

Point of care test, rapid culture, improved microscopy, phage detection (+DST) and simplified NAAT introduced.

Predictive LTBI in demonstration phase.

GP2: Development of new technology

EVOLUTION OF STRATEGY FOR TB DIAGNOSTIC TOOLSEVOLUTION OF STRATEGY FOR TB DIAGNOSTIC TOOLS

2000 TBDIStrategy informed byDELPHI(ask experts)

2003 FIND Strategy informed byEpidemiology

2005 FINDStrategy informedby• Mathematical model• Market analysis• Diagnosis delay studies

Clear need to enhance case detection to attain global TB control targets

Clear need to enhance case detection to attain global TB control targets

No of countriesimplementingDOTS

DOTS EXPANSION HAS NOT RESULTED IN BETTER CASE DETECTION RATES

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Global CNR

Source: WHO Report 2003: Global Tuberculosis Control: surveillance, planning, financing. WHO, 2003.

SOLUTIONSSOLUTIONS

Enabling industry

LIST OF TOOLS

(lower barriers to entry)

Co-investment with industry for existing applications

Product development driven

EASIER DOTS

OBJECTIVEOBJECTIVE

PRIORITISATION OF PROBLEMS

PERIODPERIOD

Current global direct expenditures on TB diagnostic testsAnnual Cost of TB Diagnostic Testing

> 1.2 billion Total :

$35,119,542* NAAT

$580,955.889Mantoux

$509,406,090Xray

$376,258,898*Culture

$324,906,257Microscopy

*Manufacturers cost applied. Reimbursement cost may be higher.

The diagnostic yield of this expenditure is limited, with only 19% of all incident TB cases detected and reported as smear-positive.*

19%

25%

27%

29%

Smear-pos reportedSmear-pos undetected/unreportedSmear-neg reportedSmear-neg undetected/unreported

2,172,000

2,366,000

1,715,000

Inefficiency of global TB case detection: 2002*

Total 8,797,000

*2004 Global TB Report, WHO

2,544,000

Availability of diagnostic services

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suspects

North America 328 37,610 0.10 64.2 0.35 226.4 0.88 570 1.46 951Europe 459 22,850 0.16 34.0 0.44 95.3 0.49 106 3.89 851Japan 127 34,510Other High Income 30 18,000 0.11 15.7 0.35 49.4 0.96 135 4.33 608Total from 22 HBC 3,892 869 0.02 1.0 0.06 3.6 1.16 67 8.06 466Rest of World 1,383 0.06 1.8 0.08 2.5 1.37 41 8.87 263Total 6,219 5,500 0.04 2.2 0.11 5.8 1.12 59 7.40 388

Culture facilities for TB are widely available in the US and Europe, with a culture-capable laboratory for every 1000-4000 TB suspects. Among the 22 countries accounting for 85% of the global TB burden, however, only Brazil and Russia have more than one culture laboratory per 10,000 TB suspects. Among the high-burden countries in Africa, culture-capable laboratories play a negligible role in TB diagnosis, with an average of only one such facility per 500,000 TB suspects (often one facility per country).

• In Lima, 22% of 259 TB patients first sought health care from pharmacists. Once getting to a physician, only 56% of TB patients were requested to submit sputum specimens and did so. In Chennai, 13% of 1000 patients being evaluated for symptomatic respiratory disease did not complete the diagnostic process, and 11% of patients in whom TB was detected were not notified of the diagnosis. In Lusaka, on the other hand, due primarily to the necessity for patients to purchase the sputum collection container, only 0.5% of patients completed the diagnostic process and only 6 of 600 patients even submitted a single sample.

• Delays to diagnosis within the health system varied widely, but were in many cases substantial, and could be limited by introducing technologies that could be used more peripherally, where patients first seek care.

EVOLUTION OF STRATEGY FOR TB DIAGNOSTIC TOOLSEVOLUTION OF STRATEGY FOR TB DIAGNOSTIC TOOLS

2000 TBDIStrategy informed byDELPHI(ask experts)

2003 FIND Strategy informed byEpidemiology

2005 FINDStrategy informedby• Mathematical model• Market analysis• Diagnosis delay studies

Clear need to enhance case detection to attain global TB control targets

Clear need to enhance case detection to attain global TB control targets

No of countriesimplementingDOTS

DOTS EXPANSION HAS NOT RESULTED IN BETTER CASE DETECTION RATES

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250

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

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Total number of countriesTotal number of countries

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Countries

Global CNR

Source: WHO Report 2003: Global Tuberculosis Control: surveillance, planning, financing. WHO, 2003.

SOLUTIONSSOLUTIONS

Enabling industry

LIST OF TOOLS

(lower barriers to entry)

Co-investment with industry for existing applications

Product development driven

EASIER DOTS

Creating new applications for existing technologies

PRIORITISATION OF TECHNOLOGIES

Only 19 % (1.7 million) of all incident cases are detected by microscopy (smear +)

Annual Cost TB diagnostic testing: 1.2 Billion $

Cost of testing: $376 million

32 M cultures performed per year

Annual cost testing: $324 million

88 million smear microscopy tests per year

Regional /

OBJECTIVEOBJECTIVE

PRIORITISATION OF PROBLEMS

2 M undetected unreported smear + patients

TB Global Incidence: 8.8 million cases

Cost of NAAT testing: $ 35 million

2.5M Molecular testings

reference

portablehighly

integratedNAT

PATIENT FOCUSED IMPACT DRIVEN APPROACH

PERIODPERIOD