14th Conference on Retroviruses and Opportunistic Infections Urgent Issues in the Developing World Transmission of Extreme Drug Resistant TB in South Africa: Discussion of the Global Implications

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Report from the Stop TB Working Groups 2009
Dr J. M. Chakaya
Stop TB Symposium "Addressing poverty through
quality TB control and research" 3 December 2009,
Cancun, Mexico
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Outline presentation

1. Key messages Global Plan to Stop TB 2006-2015
   progress report 2006-2008
2. Achievements of the Stop TB Partnership Working
   Groups in 2009 plans for 2010-2011

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The global plan to Stop TB 2006-2015 progress
report 2006-2008

• Key messages
• Number of TB patients in DOTS programmes has
  increased, as has the case detection rate
• However, progress in case detection of SS lags
  behind Global Plan expectations and gap is
  widening
• Treatment success rate in DOTS programmes has
  surpassed the targets set in the Global Plan
  reaching 85 in 2006

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The global plan to Stop TB 2006-2015 progress
report 2006-2008

• Key messages
• Progress in scaling up diagnosis and treatment of
  MDR-TB, but not enough.
• Less than 3 of estimated 500,000 cases of
  MDR-TB that occurred in 2008 are diagnosed and
  treated in GLC approved projects or programmes.
• Impressive progress in scaling up collaborative
  TB/HIV activities, particularly provision of HIV
  testing for TB patients in African countries.
• Nonetheless, the number of HIV positive patients
  started on CPT and ART is about one-third of the
  milestones set in the Global Plan, and provision
  of IPT for HIV-positive people without TB remains
  extremely limited.

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The global plan to Stop TB 2006-2015 progress
report 2006-2008

• Key messages
• The number of HBCs implementing ACSM has grown,
  but many countries are seeking further technical
  guidance.
• Based on data provided for 101 Countries with 93
  of the world's TB cases, the funding gap for
  implementation of TB control (excluding the
  Eastern European region) has been at least USD 1
  billion in each year 2006-2008.
• Funding for DOTS implementation came closest to
  matching Global Plan milestones, especially in
  2008.

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STRUCTURE OF THE STOP TB PARTNERSHIP
GLOBAL PARTNERS' FORUM
Global Drug Facility
Coordinating Board Partnership Secretariat
WHO Strategic and Technical Advisory Group
W O R K I N G G R O
U P S
DOTS expansion
TB/HIV
MDR-TB
GLI
New TB Vaccines
New TB Diagnostics
New TB Drugs
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STRUCTURE DEWG 2009 3 new subgroups
DOTS EXPANSION
ACSM subgroup
Childhood TB subgroup
HRD-TB subgroup
TB Poverty subgroup
Innovative approaches and new tools subgroup
PPM subgroup
Overall focus Achieving higher and earlier case
detection and maintain high cure.
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DEWG Plan of Action Outline

• 10 outputs defined in the DEWG plan of action
• Reinforcing support to Countries
• Monitoring Global plan implementation (WHO TB
  control report and Stop TB partnership report)
• Funding TB control in Countries
• Health system strengthening
• Human resource development
• ACSM Involvement of communities and patients
• TB and poverty
• Control of childhood TB
• Public Private Mix
• Introduction to New Approaches and new Tools
  (INAT)

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1. Reinforcing support to Countries How has
TBTEAM progressed?
2007 2008 2009 (Jan Oct)
Missions entered 281 456 1102
Requests successfully addressed 11/12 (92) 57/66 (86) 48/55 (87)
Focal points using web tool 7 14 30
Experts in roster performing missions ? 1/3 1/3
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1. Reinforcing support to Countriesselection of
TBCAP APA4 supported activities
Tool /project (Oct 2008- September 2009) Lead TBCTA Partner Description
Expanded use of planning and budgeting tool WHO 2 workshops one for 16 francophone African countries and one for GLC consultants
Dissemination of X-ray tool JATA Training workshops in use of the tool in Asia and Africa
Tool to estimate patients' costs KNCV Information from Ghana, Vietnam and Dominican Republic
Manual for TB specific DQA Tool WHO/ KNCV/ The Union Tool and guidelines - field testing in 4 Countries
QUOTE TB Light - patient centered approach KNCV Tested in Nigeria and Brazil.
Training workshops on TB Infection control, PAL, Lab culture DST WHO and The Union Capacity building for several priority countries
Institutional capacity building PMU Support to training centres in Nigeria and Indonesia
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2. Monitoring Evaluation achievements 2009

• WHO Global TB control report 2009,an update
• An update of the global TB control report is
  being published in December, reporting data from
  2008. From 2010 WHO is planning to publish the
  report towards the end of the year, reporting
  data of previous year.
• Task force on Impact Measurement
• Strengthening routine surveillance through
  regional workshops country missions
• Implementation of prevalence surveys for TB
  disease in 22 Global Focus Countries (out of
  which 16 TB HBC) - Vietnam and the Philippines
  completed survey and analysis
• Review of methods used to produce epidemiological
  estimates of the epidemiological burden of TB,
  TB/HIV and MDR-TB

See http//www.stoptb.org/tme/
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3. Funding TB Control achievements 2009

• Global Fund
• Round 9 TB
• 500M for 2 years
• 54 Countries applied
• 32 approved (59)

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4. Health System Strengtheningachievements 2009

1. HSS framework used in Global Fund proposal
   preparation and in programme reviews
2. PAL implemented in 12 Countries (expansion phase)
   and more than 40 Countries are at different
   stages of implementation or preparation of PAL
   implementation.

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5. Human Resource Development achievements 2009

1. "Planning the development of human resources for
   health for implementation of the Stop TB Strategy
   - A handbook" disseminated
2. Training modules for Management of TB at Health
   Facility level revised to reflect all components
   of the Stop TB strategy including infection
   control
3. HRD on the website of the WHO Stop TB Department
4. Establishment of a HRD-TB subgroup under DEWG
   (October 2009)

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5. Human Resource Development orientation
2010-2011

1. Annual meeting of the HRD-TB Subgroup 2 core
   group meetings
2. HRD best practice Symposia at Union Conference
3. Training material for management of TB at
   district level and supervisory levels (including
   MDR-TB and TB-HIV)
4. Collaboration with partners in related fields
   Human Resources for Health Health System
   Development the Global Health Workforce
   Alliance, etc.
5. Exchange of experiences in HRD-TB
6. TA to Countries for HRD planning, implementation
   and monitoring
7. Inclusion of HRD in all programme reviews

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6. ACSM subgroup achievements 2009

• ACSM Best Practices
• Document on how to work with media for correct
  reporting of key TB messages to a wide audience
• Revision of ACSM indicators with WHO/TME
• Criteria for TBTEAM experts roster for ACSM TA
  providers were set to ensure quality and
  consistent TA

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6. ACSM subgroup orientation 2010-2011

• Guidance on ME for ACSM and community
  involvement (Rio Recommendation)
• Support strategic planning, design,
  implementation and evaluation of ACSM
  interventions
• Advocate ACSM as cross-cutting issue affecting
  all components of Stop TB Strategy

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7. TB Poverty subgroup achievements 2009

• Advocacy
• Debate on Free Diagnosis in Partner's Forum,
  Rio de Janeiro, Brazil
• Systematic review on interventions addressing
  socio-economic conditions
• which can potentially be replicated in TB
  control
• Research
• Patient cost measurement tool piloted
• Mechanisms to increase equity in access to TB
  diagnosis in China piloted (to eliminate
• patient up-front payment)
• Measurement of equity impact through NDWG
  Blueprint and TREAT TB
• Support
• Global Indigenous STOP TB Strategy presented at
  UN Permanent Forum on Indigenous Issues
• Programme managers in 24 Chinese provinces
  trained on equity and gender
• Health systems trials in Malawi and Sudan to
  increase access to TB and HIV services
• through close-to-community providers

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7. TB Poverty subgroup orientation 2010-2011

• By 2010 all Countries will
• - have capacity to monitor extent to which TB
  control reaches the poor vulnerable
• - have key strategies for improving access to TB
  control for the poor vulnerable
• Selected directions for 2010-2011
• - Promotion of concepts practical
  implementation of free diagnosis
• - Papers on equity and PPM
• - Recruitment of indigenous TB focal person
• - Assessment of equity in access to MDR services

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8. Childhood TB achievements 2009

• Programme reviews (India, Bulgaria, Romania)
• TA to develop training and national guidelines
  (Pakistan, Philippines, Papua New Guinea)
• International Training Workshops in Cape Town
  (Sept 2009) Bangalore, Delhi and Nepal (October
  2009)
• Post-Graduate courses at Union European
  conference in Dubrovnik (May 2009) global
  conference in Cancun (December 2009)
• Systematic literature reviews to update Childhood
  TB Guidance (2006) revised instructions on the
  use of existing fixed-dose formulations
• Update of the Guidelines on INH Preventive
  Chemotherapy in HIV-infected children (work led
  by WHO HIV Department)
• Creation of a Childhood TB subgroup on New
  Diagnostics

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8. Childhood TB orientation 2010-2011

• Finalize revision of Childhood TB Guidance
• TA to Countries developing training material and
  guidelines
• Participation in programme reviews
• Post-graduate courses and symposia at the Union's
  conferences (global and regional)
• Research agenda trials in use of new
  diagnostics and new drugs in children

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9. PPM subgroup achievements 2009

• Grants awarded to 11 National Professional
  Associations to prepare ISTC implementation plans
  (ATS)
• Guiding principles on linking hospitals (KNCV)
• Pilot projects on "Engaging all care providers
  for TB/HIV collaborative activities" implemented
  in India and Namibia (Union/FHI)
• Workplace TB and TB/HIV programmes were
  documented in Bangladesh, Cambodia, Kenya,
  Philippines South Africa (WHO)
• Experience on engaging social security
  organizations in TB control documented in Mexico,
  Peru and Philippines (MSH/WHO)

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9. PPM subgroup achievements 2009

• Guidance on measuring PPM contribution to TB
  control (WHO/MSH/Union)
• "First consultation on engaging business sector
  in TB control" Geneva, 12 October 2009 (WHO)
• Supply and use of anti-TB medicines documented in
  UR Tanzania, Zambia, Brazil and India (WHO)
• PPM scale up documented in India and China (WHO)
• Preliminary analysis of PPM components of Global
  Fund grants (WHO/GF)
• PPM for MDR-TB management documented in
  Bangladesh and Philippines
• Background paper on PPM for Beijing meeting
• PPM Newsletter

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9. PPM subgroup orientation 2010-2011

• 6th global meeting of the PPM Subgroup
• PPM tool-box on evidence-based strategies to
  engage different types of public and private care
  providers
• Framework to assist Countries implement PPM
  components of their Global Fund proposal
• Revise and update PPM guidance document
• Conduct a review of best practices on regulatory
  approaches to improve service delivery (e.g. TB
  drug availability, disease notification laws,
  certification and accreditation systems)
• TA to Countries for PPM planning and
  implementation inclusion of PPM in programme
  reviews
• Guidance on engagement of large hospitals in TB
  control efforts
• Advocacy for PPM through quarterly E-updates and
  website

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10. Introducing new approaches and tools

• Terms of Reference
• Facilitate Country planning to prepare for
  coming new approaches and technologies to improve
  case detection through documents and tools
  developed by the Retooling Task Force and the new
  Working Group on Introducing new approaches and
  tools (INAT)
• Promote operational research or pilot programmes
  to develop algorithm and approaches to improve
  case detection

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10. Introducing new approaches and tools
orientation 2010-2011

• First working group meeting Feb 2010
• Regularly update pipeline for new diagnostics,
  drugs and vaccines
• Solicit NTPs implementing partners on the
  challenges of introducing new approaches tools
• Support Countries to develop a preparation plan
  for INAT
• Lead and participate in Operational Research
  and/or pilot studies
• Simulate TB control 2015 model to better advice
  Countries
• (To be confirmed by 1st Working Group Meeting in
  Feb 2010)

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GLI Achievements 2009

• New WHO diagnostic policies (STAG, Nov 2009)
• LED microscopy Same-day diagnosis "Front
  loading" Selected non-commercial culture and
  drug susceptibility testing methods
• EXPAND-TB project
• Accelerated uptake of new MDR-TB diagnostics in
  27 Countries 2009 - 2013 with state-of the-art
  commodities (instruments, tests, reagents) funded
  by UNITAID (USD 87 million over five years)
• TBCAP Laboratory Toolbox
• - Standard Operating Procedures (SOPs)
• - Logistics/Supply Management Tool
• - External Quality Assurance package (EQA)
• - Management Information System (MIS)
• - Culture DST Package

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GLI Strategic priorities 2010-2011

• Expanding access to new diagnostics (EXPAND-TB
  project) 15 Countries to be added by 2012
• WHO policy guidance on laboratory bio-safety,
  immune-based diagnostic tests, geneXpert
  molecular system
• Expansion of the Supranational Reference
  Laboratory Network
• Laboratory human resource development, in
  particular training of consultants in use of LED
  microscopy selected non-commercial culture and
  DST methods

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Working Group

• Highlights of activities in 2009
• Implementation TB/HIV collaborative activities
  expanded
• By end of 2008, 1.4 million TB patients tested
  for HIV and 1.4 million PLHIV screened for TB
• By 2008, 0.11 million HIV positive TB patients
  put on ART and 0.23 on CPT
• Expansion in Asia Pacific WG meeting in Bali in
  August 2009
• Raised TB/HIV research interest and investment
• TB/HIV Indicators harmonised
• WHO, PEPFAR, UNAIDS, Global Fund will now use
  same indicators
• TB/HIV one of nine priority areas for UNAIDS

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Working Group

• Areas of focus 2010-2011
• Nationwide scale-up of TB/HIV activities in Asia
  and Africa including TB IC activities
• European focusRegional TB/HIV WG meeting in July
  2010 in Vienna, Austria
• Promote integrated models of TB and HIV programs
  and services
• Focus on the implementation of the three I's for
  HIV/TB including WHO TB IC policy
• Finalise the guidelines for reconceptualised
  implementation of TB screening with IPT

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MDR-TB Working Group Achievements 2009

• Support to WHO in conducting the Ministerial
  meeting of High MDR-TB burden countries, Beijing,
  PR China, April 2009
• As of September 2009, the GLC has approved
  59,274 patient treatments in 108 projects
  spanning 68 Countries
• Assistance to GDF
• Research agenda focusing on scale-up of PMDT
  updated
• Research subgroup launches RESIST-TB and develops
  
• clinical trial protocols

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MDR-TB Working Group Plans for 2010

• MDR-TB Core Group
• Monitor and review progress to Global Plan,
  including both progress made under and outside
  the GLC
• Coordinate the response (i) to scale-up
  bottlenecks and (ii) imbalance between capacity
  to diagnose and treat
• Strengthen advocacy at country- and global level
  
• Strengthen collaboration with other STP WGs and
  sub-groups, especially GLI, INAT, HRD and IC
• GLC
• - Revisit GLC modus operandi in light of scale up
  from pilot projects to country wide programs
  (including TA)

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MDR-TB Working Group Plans for 2010

• Research subgroup
• Advocate for funding of clinical trials
• Develop protocol for multi-country collection
  and analysis of DR surveillance data (causes of
  DR-TB)
• Plan and advocate for programmatic cohort
  studies (diagnostic algorithms, treatment
  adherence and support)
• Support GLC and Countries on analyses of SL
  treatment data and operational research proposals
• Drug management subgroup
• Assist GDF and BAC in addressing SLD problems
• Further develop/monitor "streams of engagement"
• Systematically collect and share Country
• experiences

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Working Group on New DiagnosticsAchievements
2009

• Point-of-care diagnostics Sub-Group organized
  symposium at ESM 30th annual congress Porto
• Evidenced-based diagnostics Sub-Group established
  website www.tbevidence.org
• UNITAID project launched covering 27 endemic
  Countries (collaboration WHO/GLI, FIND and GDF)
• Total membership doubled in the last year

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Working Group on New DiagnosticsAchievements
2009

• LED-microscopy, front-loaded microscopy and
  sputum processing methods to improve microscopy
  submitted to STAG for endorsement
• Non-commercial culture methods and
  mycobacteriophage-based assays for rapid DST
  submitted to STAG for endorsement
• Publication Pathways to better diagnostics for
  tuberculosis a blueprint for the development of
  TB diagnostics
• New Paediatric TB Sub-Group established

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Working Group on New Diagnostics plans 2010

• Automated DNA detection for HIV/TB MDR-TB to
  STAG for endorsement
• Global Plan to Stop TB 2006-2015 mid-term update
• Wide dissemination of Pathways to better
  diagnostics for tuberculosis a blueprint for the
  development of TB diagnostics
• Workshop on TB diagnostic research in Montreal
• Expansion of website to include Sub-Group
  activities

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Working Group on New Drugs achievements 2009

• Reorganization of the Working Group
• Website updated to facilitate the coordination
  and communication of WGND activities
  www.newtbdrugs.org
• Survey of TB drugs RD community
• Launch online Global TB Drugs RD Pipeline
• Communications/advocacy campaign
• Workshop on Pediatric TB Drug Development

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Working Group on New Drugs Plans 2010

• Online resource on target-based screening
  campaigns
• Global survey of research activities in the area
  of tools for TB
• Increase understanding of pyrazinamide
• Develop a program to prepare clinical sites to
  conduct trials for drug-sensitive and
  drug-resistant TB

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Working Group on New TB VaccinesAchievements
2009

• 2nd meeting Economics and Product Profiles Task
  Force
• Small grants for development of community-based
  advocacy materials
• Clinical trial site staff participated in
  Tuberculosis Vaccine Trial Sites Network
  (TBVACSIN) meeting in Uganda
• Meeting on "Advancing live TB vaccines in
  clinical trials" (April 2009) publication of
  proceedings submitted to Vaccine
• Vaccine regulatory capacity strengthened through
  collaboration with the African Vaccine Regulators
  Forum (AVAREF) and the Developing Countries
  Vaccine Regulators Network (DCVRN)
• Comprehensive survey of TB vaccine candidates
• Updated TB Vaccines Pipeline overview

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Working Group on New TB VaccinesFocus in
2010-2011

• Economic estimates for TB vaccine development
  introduction
• Consensus building on issues in clinical research
  
• Increase awareness and support for new TB
  vaccines at the global and country level
• Strengthening regulatory capacity in HBCs
• Mobilizing resources for TB vaccine development
• Planning and implementing the 2nd Global Forum on
  TB Vaccine Research in 2010

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Thank you!