Expanded Response to Tuberculosis: What USAID Will Do

a) Expand and strengthen DOTS

DOTS is a cost-effective and affordable strategy for controlling TB. In general, if implemented appropriately, DOTS programs should achieve treatment success among at least 85 percent of sputum smear positive pulmonary TB patients; DOTS can also limit the emergence and spread of drug-resistant TB. DOTS can be adapted to a variety of different settings and local conditions, and the regimens used are also effective in curing TB in people who are co-infected with HIV.

USAID will support interventions to increase the availability and access to DOTS in priority countries (see Section IV below) to achieve international targets for case detection (70 percent of infectious cases detected) and treatment (85 percent of infectious cases successfully treated). More specifically, investments will be made to improve the ability of health systems to deliver sustainable DOTS programs, including: patient management including supervision of treatment; TB program management and planning skills; training personnel; strengthening laboratories; effectively procuring, delivering, and managing a dependable supply of high-quality TB drugs; educating communities on TB and appropriate care-seeking behaviors; and routinely monitoring treatment outcomes and overall program performance. Given the importance of political commitment and resource mobilization for program sustainability, USAID will assist countries to prepare national five-year plans and budgets for DOTS expansion, and to prepare proposals to funding sources such as the Global Fund to Fight Against AIDS, TB and Malaria (GFATM) and the Global TB Drug Facility (GDF).

To complement DOTS expansion efforts through national TB programs, USAID will support approaches to expand involvement of private providers, private voluntary organizations (PVOs) and non-government organizations (NGOs) in DOTS to help extend access to, and quality of, TB services. Partnerships with these groups can extend the reach of DOTS programs to marginalized or difficult to reach populations (e.g., HIV-infected, poor, minorities, migrants, just-released prisoners, and mobile populations) who often have limited access to TB services due to geographic and financial obstacles, and issues of stigma and discrimination. Coordination of in-country staff, resources, and activities will be undertaken in order to maximize impact and avoid duplication.

In addition to supporting DOTS expansion, it is equally important to strengthen existing DOTS programs to achieve better treatment outcomes, prevent disease transmission, and slow the emergence of multi-drug resistant (MDR) TB.¹ In the 22 HBCs, the case detection rate for sputum smear positive cases is 31 percent in DOTS programs, far below the global target of 70 percent. Despite the fact that DOTS programs consistently out-performed non-DOTS programs in terms of treatment success, in some high burden countries such as Pakistan and South Africa, high treatment default rates of 17 percent and 12 percent (2000 cohort in DOTS areas) respectively, contribute to disease transmission and potentially to the development of TB drug resistance. Other countries have difficulty with following up after diagnosis. Other countries have difficulty insuring that patients start treatment soon after being diagnosed with TB. Furthermore, while overall treatment success under DOTS averaged 82 percent , this global figure masks large variation in regions such as Africa where the treatment success was just 73 percent.²

USAID will undertake activities and interventions to improve DOTS program performance in USAID priority countries. Attention will be given to ensuring that diagnosed patients begin therapy, patients on treatment, as well as clinicians and nurses providing treatment and care adhere to program norms or standards, and treatment outcomes are documented and reported. Training will be provided in the correct use of TB registries and in monitoring and evaluation systems to improve data quality, and to enhance the ability of local personnel to analyze and use their data for improving programs and to influence policies. USAID will continue to support the WHO Global TB Monitoring and Surveillance project, as a key investment in providing information on the global, regional, and country level TB program and epidemiological situation. The Agency will play a key role in the development and standardization of monitoring and evaluation instruments through a global working group led by WHO. Existing tools will be evaluated and adapted, and new tools will be developed to assist USAID missions and TB program managers in the use of effective benchmarks for measuring progress and evaluating TB activities throughout the lifecycle of their programs. In countries where drug supply problems affect DOTS program performance, USAID will strengthen TB drug forecasting, procurement, inventory control, and/or distribution to ensure that reliable supplies of quality TB drugs are available.

Finally, support will be provided for operations research to assist countries in understanding local factors that contribute to weak or poor program performance and to identify appropriate corrective interventions.

¹MDR TB is defined as resistance to at least isoniazid and rifampicin, the two most-important anti-TB drugs.

²All data from The WHO Report 2003 Global Tuberculosis Control.