Diagnostic Network & Treatment Strengthening Strategies in USAID-Priority Countries

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1 Diagnostic Network & Treatment Strengthening Strategies in USAID-Priority Countries Amy Piatek (on behalf of) USAID/Global Health Bureau Washington DC April 29, 2015

2 The United States Government Lantos-Hyde Tuberculosis Strategy

3 IMPACT A World Free of TB Long term outcomes Reduce TB incidence rate by 90% by 2035 Reduce TB mortality rate by 95% by 2035 Medium-Term outcomes (by 2019) Reduce TB incidence rate by 25% Maintain treatment success rates of 90 percent for individuals with drug-susceptible TB Successfully treat 13 million TB patients Initiate treatment for 360,000 DR-TB patients Provide ART for 100% of TB-HIV infected patients Objectives Improve access to high-quality, patientcentered TB, DR-TB, and TB/HIV services Prevent TB transmission and disease progression Strengthen TB service delivery platforms Accelerate research and innovation

4 Objective 1: Improved quality patientcentered care services* Comprehensive, high quality diagnostic network Universal access to TB care is dependent upon the existence of a comprehensive and high-quality TB diagnostic network Strong laboratory networks are needed and must be adaptable to population served (e.g., urban slums, mines, workplaces, schools, prisons) A particular focus should be on improving diagnosis for TB in children Diagnostic networks should integrate all public and private laboratories from the community to the national level Patient-centered care and treatment Every individual deserves high-quality TB, DR-TB, and TB-HIV care and treatment Patient-centered care and treatment puts the individual at the center of all activities *also includes strategies around ACF, ICF, PPM, etc.

5 USAID s Mechanisms of Support Field and Regional 85% Global 15% Focus on 26 countries Plus all HBCs through regional platforms and targeted TA Response to local needs based on NTP Strategic Plan (leverage GF; COP) TA to MoHs, private sector, and NGOs (GF advisors); coordinate with partners Expansion of new approaches/ technologies (e.g., PMDT and Xpert) Global Drug Facility 5

6 USAID s Mechanisms of Support Field and Regional 85% Global policy and guideline development Major Implementers: Global operational and implementation research WHO, STB Partnership, CDC, Technical TB CARE support I and II, for Challenge evaluation, program TB, TREAT design, TB, SIAPS, monitoring, USP, mentoring, TB Alliance, and TB project TEAM, etc. management Global 15% 6

7 DIAGNOSTICS 7

8 Central: Support to GLI policies, guidelines (Accreditation, Lab network plan, etc.) Capacity bldg, infrastructure at National TB Reference Lab Quality assurance systems Supranational lab support (EXPAND TB TA) / new SRLs DRS USAID s Support: Overall Diagnostic Networks Intermediate and Peripheral: Sputum transport/referral systems Capacity bldg, infrastructure in intermediate and peripheral labs Rolling out/scaling-up diagnostics

9 USAID s Support: Xpert MTB/RIF USAID/USG continues to support the scale-up of Xpert to quickly and accurately detect rifampicin-resistant and HIVassociated TB, including children and EPTB. Overall, USAID/USG support for Xpert began with intensive technical assistance, training and procurements extended to provide extensive mentoring, supervision, and monitoring activities. Many countries are utilizing this technology in innovative ways such as hub-and-spoke models for greater coverage of services A USAID-supported pilot of the use of Xpert to test PLHIV in Nigeria and Zimbabwe has utilized and optimized field conditions to ensure that PLHIV with symptoms of TB are offered Xpert as the initial diagnostic test. **Will utilize experience/tools, etc. for the roll-out of new diagnostic tools as they become available. 9

10 DRUGS 10

11 USAID Support to Manufacturers ( ) Strengthen QA/QC systems Provide TA to manufacturers in GMP compliance Conduct training and education in quality control procedures Advocate for the importance of medicines quality globally Shape the market through increased product availability

12 *GDF data USAID s Impact on SLD Prices (2012 vs. 2015)

13 Drug Management Systems Approach Establishment of Early Warning System (EWS) Introduction of electronic recording and reporting and other tools to quantify TB commodities Training in pharmaceutical management to strategically improve and strengthen the system Engagement of the private sector in TB pharmaceutical management Monitoring progress of countries

14 COUNTRY EXAMPLES: DELIVERY OF CARE 14

15 Shift to Community PMDT: Nigeria (TB CARE I/KNCV) Challenges Only 10 hospitals (MDR wards) with fewer than 200 beds capacity Long hospitalization for 8 months Waiting list for enrollment nationwide after Xpert scale-up Patient refusal for hospitalization Frequent industrial action/strikes by health care workers in public health facilities Ebola crisis (35 displaced MDR pts) 125 enrolled by end of 2014 Excellent intermediate results Expanded by GF to 10 additional states Solutions/Activities Revision of national PMDT guideline to incorporate mix model of care (primary enrollment at the community or shorter admission period of 3 months;) all these with clear criteria Development of SOPs and capacity building for 10 states Development community hand book for field workers Provided patient support to enable daily DOT Provide support for effective community supervision 15

16 mhealth cpmdt program: Bangladesh (TB CARE II/URC) Objectives: Enable MDR-TB treatment at home Monitor DR TB DOT providers Monitor treatment compliance Seek quick management for ADR Record DR TB DOT provider and DR TB patient status Assist with contact tracing and track patient referrals, etc. Results: 395 DOTS providers monitored down to sub-district level Key information available Treatment compliance improved Preliminary outcomes: 90% cure

17 Evaluation of Loss-to-Follow-Up during MDR-TB Treatment: Philippines (USAID/CDC) Challenges >30% loss to follow up rates seen in cohorts wide variation among facilities <50% treatment success cohorts Results Factors for LTFU Alcohol abuse Patient confidence to adhere to treatment Vomiting severity Side effects/fear of side effects Intervention Retrospective case-control study Total 273 patients enrolled 91 Cases (loss-to-follow-up) 182 Controls Guided by 5-level sociological model (social; diag & trt; health setting; interpersonal; individual factors) Protective Factors Receiving any assistance TB knowledge Trust/rapport with treatment center staff *Based on results, NTP developing pilot cpmdt program, improved incentives & enablers, and training for health staff on management of side effects. 17

18 Linking Diagnostics, Drugs and Delivery of Care USAID strives to provide quality, integrated support to countries by: Linking a comprehensive network of quality diagnostic services to patient-centered treatment and care approaches Offering effective and inexpensive treatment within a drug management system Working with MoH, NTPs and key stakeholders and sectors while efficiently leveraging support of GF, PEPFAR and other donor agencies and technical partners Helping countries to strengthen programs through innovations in TB care and prevention

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