Leading and Leveraging: U.S. Government report on International Foreign Assistance in TB FY 2010

EXECUTIVE SUMMARY

The U.S. Government’s (USG) tuberculosis (TB) program is mainly implemented through USAID as the lead agency in international TB control, in close collaboration and coordination with U.S. Centers for Disease Control and Prevention (CDC), Department of State/ The Office of the Global AIDS Coordinator (OGAC), the National Institutes of Health (NIH), and Department of Defense (DoD). The U.S. Government continues to prioritize support to countries with high rates of TB and multi-drug resistant TB (MDR-TB), lagging case detection, poor program performance, and where the HIV epidemic is a driver of TB disease. This prioritization of countries led to investments in 20 “Tier 1” or focus countries, with funding levels of at least $3 million per country; and in 21 “Tier 2” countries, with smaller but strategically targeted interventions.1 Sustained and well-focused investments in fighting TB have begun to make their mark on the global TB burden. By 2010, death and prevalence rates in Tier 1 countries had decreased 29 percent and 14 percent, respectively, compared with 1990 levels. Detection of all forms of TB cases in U.S. Government TB programs reached 60 percent in 2010, and treatment success rates reached 85 percent, the global target, for the 2009 cohort of TB cases. Significant progress is being made to achieve the Global Health Initiative (GHI) targets for TB.

In 2010,2 3.8 million TB cases were detected in countries supported by the U.S. Government’s TB control program, which is a 51 percent increase since 2000. In the past year, millions of lives were saved and tens of millions of additional cases of TB were averted. Of the almost $249 million obligated by USAID for TB in 2010, 85 percent directly supported the country and regional level programming that enabled these gains. The remaining 15 percent supported global-level goods, such as surveillance, evolution of normative technical guidance, and research into shorter drug regimens.

The U.S. Government technical approach emphasizes support to innovative and quality-assured programs in TB endemic countries, progressive leadership internationally, and deliberate coordination with other stakeholders to ensure the most efficient use of funds. With its strong field presence, USAID works closely with disease endemic country governments to assess and respond to existing constraints in the health system and TB program that impede the provision of quality TB control services. With such in-depth country knowledge and presence in TB, the programs are uniquely positioned to share successful approaches between countries and to recognize common bottlenecks to implementation that may require a shift in the global policy, guided by operational research. Driven by evidence, innovative new approaches to care are promoted to make services more efficient and patient-centered, while improving quality.

Many of the flagship projects are making important contributions toward universal access to care. Two such initiatives aim to extend access to care beyond public sector health facilities, by a) engaging all care providers such as private sector practitioners, hospitals, pharmacists, prisons, social security, and health insurance organizations; and b) enabling community-based care. The contribution of these providers to case detection was notable. In Nigeria, for example, nearly 34 percent of the cases put on treatment came through private clinics and hospitals; in Cambodia, 17 percent of cases were identified through pharmacies and private providers. In Afghanistan, community health workers detected more than 30 percent of all cases detected nationally.

The U.S. Government demonstrated leadership in addressing the increased case load of MDR-TB as staff contributed to the development of new technical guidance and globally recognized policies. Country-based USAID programs launched some of the first diagnostic and treatment sites for MDR-TB in those settings. There were 19,121 persons initiated on MDR-TB treatment in 2010 in USAID supported sites—a 63 percent increase over 2009.

USAID TB resources leverage U.S. President’s emergency Plan for AIDS Relief (PEPFAR) funding led by the Office of the U.S. Global AIDS Coordinator (OGAC) at the Department of State to strengthen country efforts to coordinate TB and HIV activities, increase early detection of TB and HIV, and expand access to integrated TB and HIV treatment. These TB resources have contributed significantly to country momentum in scaling up TB/ HIV activities. HIV care to TB patients, especially HIV counseling and testing, cotrimoxazole preventive therapy, TB diagnosis, and anti-retroviral treatment in co-infected patients, has been scaled up in most USAID-supported TB/HIV high burden countries. By 2010, 58 percent of registered TB patients were tested for HIV in USAID-supported countries with TB/HIV activities compared to a global average of 26 percent.3 exercising its comparative advantage in pivotal, late-stage research that stands to influence practice in high-endemic countries in the near term, the U.S. Government continued to invest in several areas of research. New short course regimens containing two new drug compounds that may shorten the duration of treatment have continued to progress through the development process. USAID is supporting a clinical trial of a drug regimen for MDR-TB that could cut treatment time in half. Operational research has also supported the rapid and appropriate roll-out of several new diagnostic technologies that are endorsed by the World Health Organization (WHO).