Memorandum submitted by Lucy Chesire,
ACTION Project-Kenya
INTRODUCTION
This submission will attempt to address issues
around TB/HIV co-infection, the strategies currently in place
and the concerns around DFID's AIDS Strategy.
TB/HIV—BACKGROUND
INFORMATION
TB remains a major public health problem, although
Africa is worst hit by both epidemics of TB and HIV. The deadly
synergy between TB and HIV continues to cause havoc around the
world. The World Health Organization realized this and declared
TB a global emergency in 1993. Global targets and indicators have
been developed within the framework of the Millennium Development
goals, as well as by the Stop TB Partnership and the WHO World
Health Assembly. The impacts are to halt and reverse TB incidence
by 2015 and to halve prevalence and death rates by 2015 compared
with the baseline of 1990.
The Stop TB Strategy spells out what countries
need to do in addressing TB. This includes:
1. Pursuing high quality DOTS expansion and enhancement.
2. Addressing TB/HIV, MDR-TB and other challenges.
3. Contributing to Health System Strengthening.
4. Engaging all care providers.
5. Engaging people with TB and communities.
6. Enabling and promoting Research.
THE CHALLENGE
Recognising that we can't fight AIDS unless
we do much more to fight TB, which has been rated as the leading
cause of death among people living with HIV/AIDS. TB is a disease
linked with poverty and thus the need to ensure that HIV in the
contextual field means also being able to incorporate TB/HIV strategies
into the country plans so that they have a coordinated response.
SCALE OF
THE CHALLENGE
REMAINS HUGE
— 1,500 die every day from TB in Africa,
this amounts to 2.3 million TB deaths yearly around the world.
Among the 9.2 million new TB cases in 2006, WHO estimates that
around 709,000 were HIV positive. This estimate is based on the
global estimates of HIV prevalence among the general population
(all ages) published by the Joint United Nations Programme on
HIV/AIDS(UNAIDS) and WHO in December 2007, as well as data on
the relative risk of developing TB in HIV positive and HIV negative
people.
— The African region accounts for 85%
of the HIV positives cases in 2006. Countries like South Africa,
has 0.7 of the world's population but accounts for 28% of the
global number of HIV positive TB Cases and 33% of the HIV cases
in the African Region. Kenya like South Africa has seen an increase
in the number of MDR-TB infections over the years. The sad part
is that we do not know the scale of Extensive Drug Resistant TB,
as Kenya does not have the capacity to be able to detect this.
African countries are seeing an increase with the emerging challenge
of MDR-TB, which has resulted from non-adherence to DOTS treatment,
poor treatment management and due to under investment in TB control
efforts. The worse of it is, is that it is more expensive to treat
MDR-TB as it takes two years treatment at a cost of 20,000 USD
per patient. Countries need to implement the Stop TB Strategy,
which outlines measures to be able to deal with all TB challenges.
DFID has the potential to ensure support for such cost effective
interventions.
COMPONENTS OF
THE STOP
TB STRATEGY
The Stop TB Strategy was launched by the World
Health Organization in 2006. It set out the interventions that
need to be implemented to achieve the Millennium Development Goals
and World Health Assembly targets.
The second component dwells on TB/HIV, MDR-TB
and other challenges.
The goal of the TB/HIV collaborative activities
is to be able to reduce the burden of TB and HIV in dually affected
populations. Three objectives are well spelt out to include:
— Establish Mechanisms for collaboration
between TB and HIV programmes.
— Decrease the burden of TB among people
living with HIV.
— Decrease the burden of HIV among
TB Patients.
ESTABLISHING MECHANISMS
FOR COLLABORATION
These include:
— TB/HIV coordinating bodies.
— HIV surveillance among TB patients.
— TB/HIV monitoring and evaluation.
DECREASE THE
BURDEN OF
TB AMONG PEOPLE
LIVING WITH
HIV
The elements are commonly referred to as the
3 Is.
— Pursuing Intensified TB case finding
among people living with HIV.
— Proving Isoniazid preventive therapy
to PLWHA to reduce the burden of TB.
— TB infection control in care and
congregate settings.
DECREASING THE
BURDEN OF
HIV AMONG TB PATIENTS
— HIV testing and counselling.
— HIV preventive methods.
— Cotrimoxazole preventive therapy.
— HIV/AIDS care and support.
— Antiretroviral therapy to TB patients.
Implementing TB/HIV activities is a sure way
of ensuring that people living with HIV, stop dying from TB in
an era where anti-retroviral therapy is becoming readily available
to those who need it.
INTERNATIONAL RESPONSE
During the AIDS Conference 2008 held in Mexico,
it was revealed that a mere 1% of people living with HIV around
the world are being screened for TB. This is contrary to WHO targets
that emphasize the need for all PLWHA to be screened for TB frequently
and if found to be smear positive to be initiated on ART. The
report further noted that of the more than one in every four PLWHA
had TB.
HIV country programmes have not only been slow
in responding to the dual epidemic, but donors have also turned
a deaf ear to the synergy between the two diseases. The majority
of HIV positives being initiated on ART are people living with
HIV, classified by WHO as Category 3 and require ART. We are also
further aware of the complexities around starting ART with TB
treatment due to the interactions among Rifampicin and Nevirapine.
This notwithstanding, there are regimens that can be used to address
this. Internationally PEPFAR and the Global Fund to fight AIDS
are the two leading donors in responding to the epidemic, but
they have fallen short of screening all people living with HIV
for TB, and even monitoring them on a frequent basis.
Countries are two years from the global targets
set in order to be able to achieve universal access to HIV treatment
care and prevention. At the progress being made, many countries
will not be able to achieve this, as the upsurge of TB continues
to undermine the progress made in the fight against HIV and AIDS.
Civil society is thus calling for more action to address the dual
epidemic in order to avert the unnecessy deaths caused by TB,
an old disease that is curable, treatable and preventable. The
emergence of multi-drug resistant TB among people living with
HIV and AIDS in South Africa should be used as an opportunity
to address the twin diseases.
DFID HIV/AIDS STRATEGY
DFID's AIDS strategy is more focused on strengthening
health systems, which for many years have been down-graded due
to donor conditionalities like the IMF policies on health, which
were a necessary evil. Sadly with the launch of the New DFID strategy
of 2008, HIV/AIDS has taken a back bench position, and this approach
will have repercussions in the fight against HIV and TB in the
coming years, considering that these are programmes that have
yielded specific results. And saved many lives over the years.
In 2007 DFID spent about 500 million pounds on Health, of which
130 millions pounds went into HIV/AIDS, however come 2008, the
Health strategy does not have specific indicators and outcomes
for Health Systems Strengthening and this becomes a major challenge
in holding DFID to account on what it is planning on HSS.
The Stop TB strategy realizes health systems
strengthening as one of its major elements and thus the need for
countries to be able to operationalize and implement how through
TB programmes they will be able to contribute to health systems
strengthening. Recognizing the role that vertical and horizontal
programmes play, it is thus very important that DFID ensures that
Health system strengthening efforts do not in any way undermine
the gains made in addressing both TB and HIV over the years.
RECOMMENDATIONS TO
DFID
1. There is a need for DFID to understand the
number of lives saved through support to Vertical and Horizontal
programmes and this becomes an opportunity, to recognize the role
such programes play in the context of Health System strengthening.
2. Implementation of TB/HIV collaborative efforts
is a sure way of addressing the emerging challenge of co-infection
around the world. Efforts towards this should be highly supported
by the donor community and DFID has an opportunity to provide
leadership in this alongside PEPFARS initiatives.
3. DFID needs to evaluate its priorities on funding
in order to be able to line up and complement Country Action Plans
and emerging global challenges like Multi-drug resistant TB and
XDR-TB.
4. DFID may highly consider other funding opportunities
besides current support given to the Global Fund to fight AIDS,
TB and Malaria.
5. Monitoring and Evaluation are critical components
of country programmes, yet it is still very unclear in the current
Health System strengthening strategy how DFID will carry out its
M and E.
6. DFID should come out very clearly and tell
us what targets and indicators they are setting for Health System
strengthening and how different partners will be able to work
collectively to achieve this.
7. Lastly, coordination among country donor partners
remains a major challenge in many countries. What role can DFID
play in its Health strategy in fostering this, so that countries
can move forward and work beyond ensuring health for all globally?
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