Framework and Standards for Effective TB Control

1. Interim Draft Module 2 - September 2008 Framework and Standards for Effective TB Control

2. Project Partners • Collaborative project Funded by the United States Agency for International Development (USAID)

3. Module Overview • DOTS Strategy • The Stop TB Strategy • International Standards for Tuberculosis Care (ISTC) • National Tuberculosis Programme (NTP)  STOP TB!

4. Learning Objectives Objectives: At the end of this presentation, participants will be able to: • Describe the components of the DOTS Strategy and the Stop TB Strategy • Describe the purpose and content areas of the International Standards for Tuberculosis Care (ISTC) • Describe the structure of the National TB Programme (NTP) and potential areas for collaboration with the National HIV/AIDS Programme (NAP)

5. The Global Emergency • In 1993, the WHO declared TB a global emergency due to it’s increasing importance as a public health problem • Contributing Factors: • Poverty • Population growth • Migration • Concurrent HIV epidemic • The Directly Observed Treatment Short-course (DOTS) Strategy was developed as a response to the global emergency

6. CAREC’s Response • CMCs grouped according to TB burden • Policies and guidelines developed • Networking with regional and international partners (PAHO; CARICOM; WHO; CDC; Health Canada) • Establish/strengthen critical laboratory support structures (in-country; CAREC) • Training Laboratory ; other NTP personnel • TB/HIV collaborative efforts

7. The DOTS Strategy The 5 Components of the DOTS Strategy: • Sustained political commitment • Access to quality-assured sputum microscopy • Standardized short-course chemotherapy for all cases of TB under proper case management conditions, including Directly Observed Treatment (DOT) • Uninterrupted supply of quality-assured drugs • Recording and reporting system enabling outcome assessment of all patients and assessment of overall program performance

8. The Stop TB Strategy • In 2001, the first Global Plan to Stop TB (the Stop TB Strategy) was launched through the Stop TB Partnership • The goals of the Stop TB Strategy are: • Ensuring access to treatment and cure • Protection of vulnerable populations from TB • A reduction in the social and economic tolls of TB on families, communities, and nations • The Stop TB Strategy Builds on and enhances the DOTS Strategy to meet the Millennium Development Goals (MDG)

9. Millennium Development Goal (MDG) Targets: • MDG 6, Target 8; halt and begin to reverse the incidence of TB by 2015 • Epidemiological targets linked to the MDGs and endorsed by 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 • by 2050, eliminate TB as a public health problem (i.e., <1 case/million population per year)

10. Stop TB: Critical Components

11. (ISTC) www.istcweb.org

12. International Standards for Tuberculosis Care (ISTC) • These 17 standards of TB care pull together research findings and clinical expertise to provide guidance based on evidence and experience over time • ISTC companion documents include: • Patients’ Charter for Tuberculosis Care • Handbook for using the International Standards for Tuberculosis Care

13. ISTC Collaborators

14. International Standards for TB Care • Diagnosis Standards – ISTC #’s 1 – 6 • Treatment Standards – ISTC #’s 7 – 15 • Public Health Standards – ISTC #’s 16 – 17

15. National TB Programme (NTP) • The aim of the NTP is to reduce the morbidity, mortality, and disease transmission, while preventing the development of drug resistance • In settings with high HIV and AIDS prevalence, these strategies should be coordinated with those of the National AIDS Programme (NAP)

16. National TB Programme (2) • The short-term programme objectives are: • To achieve a cure rate of 85% among new sputum smear positive tuberculosis patients • To detect 70% of existing cases of sputum smear positive tuberculosis • To prevent the emergence of acquired drug-resistant M. tuberculosis

17. Essential Components of the NTP Activity

18. NTP: Key Features • A central unit • NTP manual available at the level of the periphery • A tuberculosis management information system using standardised registers • A training programme covering all aspects of the NTP policy package • A nationwide network of quality assured microscopy services in close contact with primary health care (PHC) services and subject to regular quality control

19. NTP: Key Features (2) • Treatment services within the PHC system, with priority for directly observed short-course chemotherapy • Uninterrupted supply of quality assured drugs and diagnostic materials with reliable procurement and distribution systems • Plan of supervision

20. NTP: Key Features (3) • Mechanisms for stakeholder and health service collaboration with special attention to TB and HIV operations • A project development strategic plan, with budget details, funding sources and responsibilities • Information, education, communication and social mobilization to empower patients and communities

21. NTP: Activities • Early and intensified case-finding supported by: • Voluntary counselling and testing, or • Provider-initiated testing for HIV and TB detection • Administering adequate treatment to achieve cure under DOT supervision

22. NTP: Structure • NTP activities should be integrated into the existing health care services • Health care workers of the general services health unit must be aware of the mechanisms for case-finding and treatment • Shared responsibility and assistance with facilitating and implementing the process • Mandatory that managerial and supervisory staff are responsible for the TB specific technical competence of all health care workers in the programme

23. NTP: Structure (2) • The NTP structure must also reflect: • The multi-disciplinary approach to surveillance and case management • The mechanisms for implementing TB and HIV collaboration • Headed by a programme manager responsible for: • Planning the work of the programme • Collaborating with health care staff in the periphery • Regional/District/Parish level coordinators assist with supervising TB control activities at their level

24. Collaboration Between TB and HIV/AIDS Programmes Guiding principles for collaboration: • Prevention of HIV should be a priority for TB control given the impact HIV has on TB morbidity and mortality • TB care and prevention should be a priority for HIV/AIDS programmes given the high morbidity and mortality from TB among people living with HIV/AIDS (PLWHA) • Joint TB/HIV programme planning, implementation and coordination of activities is critical to the successful control of both diseases

25. Areas for Collaboration • Areas for potential TB and HIV/AIDS collaboration: • Advocacy • Policy consensus • Information, education, and communication (IEC) strategies • Training activities • Procurement and distribution of drugs, consumables, laboratory reagents • Monitoring and evaluation TB

26. Areas for Collaboration (2) • Areas for potential TB and HIV/AIDS collaboration (continued): • Information systems • Surveillance and referral • Counselling and testing services • Provision of preventive therapy • Provision and supervision of Antiretroviral Therapy (ART) and TB treatment TB

27. Health Promotion, Communication, and Education • Formulate health Public Policy: • Promote health as a strategic input and priority outcome of Public Policy development • Re-orient health services through: • Response to needs of individuals and communities • Health professional’s recognition of partnership with communities and individuals • Promote curative and preventive patient centered care

28. Health Promotion, Communication, and Education (2) • Empower communities to achieve well-being through: • Collaboration within communities to determine priorities • Facilitate and support community action plans • Provide information and skills for community to take action

29. Health Promotion, Communication, and Education (3) • Build alliances within the community: • Special emphasis on media collaboration • Access and pool resources from all sectors of the for the promotion of health • Form alliances with other government sectors: education, social and community development, culture, gender affairs, youth and sports organizations • Include Non-Governmental Organisations, faith based organisations, service clubs, and NAPs

30. What Health Promotion, Communication, and Education activities have you been involved with?

31. Goal and Objectives Goal To decrease the burden of TB and HIV in dually affected populations Objectives • to establish the mechanisms for collaboration between TB and HIV/AIDS programmes • to decrease the burden of TB among people living with HIV/AIDS • to decrease the burden of HIV in Tuberculosis patients

32. TB/HIV Objectives and Activities • Establish the mechanisms for collaboration • Set up a coordinating body for TB/HIV activities • Conduct surveillance of HIV prevalence among TB patients • Conduct surveillance of TB prevalence among HIV patients • Carry out joint TB/HIV planning • Conduct monitoring and evaluation

33. TB/HIV Objectives and Activities (2) • Decrease the burden of TB in people living with HIV/AIDS • Establish intensified tuberculosis case-finding • Introduce isoniazid preventive therapy • Ensure TB infection control in health care and congregate settings

34. TB/HIV Objectives and Activities (3) 3. Decrease the burden of HIV in tuberculosis patients • Provide HIV testing and counselling • Introduce HIV prevention methods • Introduce co-trimoxazole preventive therapy • Introduce anti-retroviral drugs

35. Joint TB/HIV Activities TB DOTS +VCT +Condoms +HIV surveillance HIV VCT + TB screening IEC STIs ARVs TB/HIV Intensified case-finding Isoniazid preventive therapy Co-trimoxazole preventive therapy Home- and community-based care General Health Services

36. Category I Countries with national adult HIV prevalence rate 1% OR Countries in which national HIV prevalence among tuberculosis patientsis  5%. Category II Countries with national adult HIV prevalence rate below 1% AND Administrative areas that have adult HIV prevalence rate 1% Category III Countries with national adult HIV prevalence rate below 1% AND No administrative areas with adult HIV prevalence rate 1% Implement all 12 recommended collaborative TB/HIV activities Implement all recommended collaborative TB/HIV activities in administrative areas with HIV prevalence > 1% and in other areas as in Category III Implement HIV surveillance among TB patients (A2) And Activities to decrease the burden of TB in PLWHA (with special emphasis on high HIV risk groups) – (B1,2,3) Thresholds for Collaborative TB/HIV Activities Category Recommendation

37. Summary • The DOTS Strategy, the Stop TB Strategy, and the ISTC are key responses to addressing the high global tuberculosis prevalence • While NTP structure varies by country, a cohesive and well organized program is essential for effective TB prevention and control • Health promotion, communication, and education are necessary for patients, staff, and the community • Where possible, collaboration between TB and HIV/AIDS programmes can greatly improve the effectiveness of both the NTP and NAP