Botswana

Country DirectorDiriba Agegnehu Lead PartnerKNCV

Challenge TB Botswana focuses mainly on the provision of technical support from both in-country and periodic international expert technical advisors in various technical areas of TB and TB/HIV control. Through Challenge TB, one senior technical advisor is full-time seconded to the Botswana National Tuberculosis Control Program (BNTP) and one senior laboratory advisor is full-time based at National TB Reference Laboratory (NTRL).

KNCV Tuberculosis foundation, through USAID funding, has been working closely with the Botswana Ministry of Health since 2006. KNCV has been actively supporting capacity building at both the National TB program and the National TB reference laboratory. Our strong partnership with Ministry of Health enabled some key achievements:

• Development & implementation of National Strategic Plan for TB control and TB laboratory.
• Global Fund support: full life cycle from epi-analysis and national strategic plans to concept notes and full implementation.
• Expansion of community TB care, Public-Private-MiX (PPM) engagement, MDR-TB, TB/HIV and TB infection control.
• GeneXpert roll-out, implementation of Quality Management Systems, and culture & DST at the NTRL.

DR Congo

Country DirectorJean Pierre Kabuayi Lead PartnerThe Union

In 2013, the TB incidence notified in the Democratic Republic of the Congo (DRC) was 94/100,000 inhabitants for new case and 149/100,000 for all TB forms The case detection rate estimated by WHO for TB all forms was 51% (47-56) for 2013 in the 23 Coordinating Facilities Against Tuberculosis (CPLT). The epidemic of HIV infection is generalized with a prevalence of 1.2 percent in the general population. The highest rates are in Maniema (4%), and the lowest are in Bas Congo (0.2%), the percentage of HIV among TB patients notified in 2013 was 14%. The total number of pulmonary tuberculosis (PTB) cases notified in 2013 was 113,603. Among them 71,526 were new cases smear positive (SM+), 3,981 were relapses and 1,164 were other cases previously treated. The proportion of MDR-TB among TB patients was estimated at 2.6% (0.01-5.5) among new SM+ PTB are MDR-TB and 13% (0.2-28) among retreatment cases (WHO 2014).

Challenge TB is a five year USAID funded project supporting the National TB Program (NTP) with implementation of the national strategic plan for TB. The project leader is The Union, which coordinates the project and provides the National Program Against Leprosy and Tuberculosis (NPLT) with the necessary support in implementing priority activities not covered by Global Fund and other donors at national and CPLT levels. The Union works with MSH, which will support the NPTL for implementing a minimum TB/HIV intervention package in the 54 health zones of the three provinces where PEPFAR projects are already under implementation.

The major challenges identified are the following and will be covered by Challenge TB:

• Increase TB detection by promoting new initiatives such as detection/treatment of TB in children, active case finding in high-risk groups (e.g. prisoners, miners, displaced population)
• Increase detection and treatment success of MDR-TB
• Improve integration of care for TB/HIV patients
• Improve quality of care and support patients with TB and TB/HIV
• Strengthening surveillance and operations research

Challenge TB provides Technical Assistance (TA) and logistic at central and provincial level, additional recipients of TA include community organizations and other local partners such as CAD, LNAC, Ambassadors, Femmes plus and Initiative Inc.

East Africa Region

Country DirectorVictor Ombeka Lead PartnerKNCV

Under the USAID funded Challenge TB five year Project the East Africa Regional program is a nine month program funded by the USAID East Africa. The program focuses its activities in six priority countries in the region namely Ethiopia, Kenya, Rwanda, Somalia, Tanzania and Uganda. The project is designed to cover activities that are beyond individual countries and to develop demonstration/learning sites through which best practices can be generated and shared for adoption and implementation.

The priority technical focus areas for the Challenge TB Regional project are:

1. 1. Cross border TB control to promote cross-country collaboration and coordination for improved TB control and surveillance across national borders.
2. 2. Supporting National TB reference laboratories to address diagnostic capacity in key and vulnerable populations.
3. 3. Strengthening PMDT to improve: access to second line TB drugs including new drugs and shorter regimens and M/XDR-TB case holding and palliative care.
4. 4. Building capacity on Childhood TB by establishing a network for sharing and learning and its incorporation into continuing education on TB and Maternal and Child Health (MCH).
5. 5. Creating a Regional Training Corridor by linking training institutions and earmarking them for specific trainings in TB.

This project will work closely with the East Central and Southern Health Community (ECSA-HC), the Rwanda Center of Excellence (CoE) for programmatic management of drug resistant TB (PMDT), and the Supranational TB reference laboratory (SNRL) in Uganda and will focus on regional cross-cutting issues namely:

• Cross-border TB control to promote cross-country collaboration and coordination for improved TB control, surveillance and referral across national borders; This will consist of a patient referral system, cross-border planning and coordination meetings in the participating countries (Kenya, Somalia, Tanzania and Uganda) and the lessons learned will be scaled-up to all ECSA member states.
• Supporting national TB reference laboratories to address diagnostic capacity in key and vulnerable populations; Critical support for staff retention in part of the first year.
• Strengthening PMDT to improve access to second line TB drugs including new drugs and shorter regimens and M/XDR-TB case holding including palliative care; will focus on identifying a country/site to implement palliative care for M/XDR TB failures. This demonstration site will also be prepared for the eventual introduction of shorter/new drug containing regimens and will be a learning point for the other countries. It will also support a regional dashboard for second line medicines at ECSA HC for easy tracking the medicines in the region and sharing.
• Building capacity on Childhood TB by establishing network for sharing and learning and incorporation of it into continuing education on TB and Maternal and Child Health; Through the Union the project will develop a facilitator guide for the new ‘Childhood TB for healthcare workers’ e-learning course (www.childhoodtb.theunion.org). This guide will prepare facilitators to host an online training course for healthcare workers at the primary and secondary level of care. The project will also develop a four-module e-learning course on the management of pediatric MDR-TB. This course will be hosted on the Union’s Childhood TB Learning Portal and target specialist doctors and other healthcare workers who manage MDR-TB in children. The course will be developed in collaboration with The Sentinel Project on Pediatric Drug Resistant TB (www.sentinel-project.org).
• Creating a Regional Training Corridor by linking TB training institutions and earmarking them for specific trainings in TB. The corridor will provide a range of training on several topics of TB complementing each other’s capacity in some areas. This corridor will provide an easy and convenient access to TB trainings for the countries in the region. The trainings will be linked to the proposed Institute for infectious disease under the ECSA College of Health Sciences. The PMDT Center of Excellence in Rwanda will be supported to get accreditation in the region.

Ethiopia

Country DirectorAhmed Bedru Lead PartnerKNCV

USAID support in Ethiopia started in 2008 with TB CAP after which support under TB CARE I followed (2010-2014) and subsequently Challenge TB (2015-2019).The Challenge TB project has been designed in alignment with the Ethiopia TB NSP (2013/14-2020) and the post 2015 global end TB strategy with a focus on three major areas of support:

1. 1. Comprehensive regional level support and technical assistance.
2. 2. National level technical assistance.
3. 3. Support for Urban TB activities.

In its first year implementation strategy, Challenge TB Ethiopia will focus on Improving quality of TB services ( both in terms of access and service utilization as well as patient-centered care), increasing case finding (both in terms of targeted active case finding (ACF) and diagnostic capacity) and enhanced sustainability and strengthening health systems at all levels.

Challenge TB Ethiopia will work in two rural agrarian regions (SNNPR and Tigray) and three urban districts (Addis Ababa, Dire Dawa, Harari). Strengthening community TB care service (Challenge TBC) in Ethiopia’s decentralized health system using new and innovative strategies will be key. There will be a focus on Ethiopia’s three key populations (rural, pastoralist and urban) working towards improving service utilization in terms strengthening referral linkages at all levels, ensuring available technologies like GeneXpert are optimally used at all levels with special attention to ensure MDR-TB cases benefit optimally both in terms of case finding as well as linkage of services optimizing patient centered care.

In addition, the project will work to address challenges to ensure quality diagnostic capacity, TB/HIV collaborative activities, Pediatric TB, TB in prisons, TB-IC, Contact investigations and active case finding. It will also strengthen the health systems at all levels by building strong technical programmatic capacity for TB control both nationally as well as in the two focus regions and in urban setting. An overarching theme will be data quality and operations research support to enhance TB control.

Malawi

Country DirectorAnthony Abura Lead PartnerKNCV

Malawi continues to be severely burdened by the TB-HIV epidemic. Provisional results of the nationwide prevalence survey in October 2014 indicate a TB prevalence of 286/100,000 for bacteriologically confirmed PTB which is almost 2 times higher than previously estimated by WHO; with a 1.4 higher prevalence in men than women, and a 2.7 higher prevalence in urban as compared to rural areas (although not statistically significant), and higher TB prevalence in persons aged 35-45, 55-64, and 65+. With an HIV prevalence in the general population of 10.8% and among TB patients of 56%, HIV remains the most important risk factor for developing active TB disease. The geographic distributions of TB is similar to the distribution of HIV in Malawi and routine service data indicate that the high TB and HIV burden tend to overlap in urban centers and the southern part of the country.

Challenge TB Activities will focus on:

Alignment with NTP Strategic Plan and Global Fund Concept Note, and close coordination with NTP and other relevant TB and HIV technical partners;

Increasing case detection in each of the geographic focus areas. This will be achieved by targeted implementation of intensified case-finding in all health facilities, targeted active case-finding (e.g. mobile teams and digital chest X-ray screening), contact investigation, as well as other interventions (community sputum-collection centers, community mobilization) which have been well evaluated for their costs and effectiveness;

Strengthening NTP leadership at central level, zonal level and a number of selected districts;

The project will collaborate closely with PEPFAR supported partners, both at national and district level, to maximize synergy in project operations on improving TB prevention and care for PLHIV. This includes: capacity building on 3I's, specimen sample transportation, M&E, laboratory strengthening, etc;

The project will strengthen the leadership of NTP in coordination and planning of operations research, sharing of research results and reaching consensus on policy implications for NTP.

Mozambique

Country DirectorRobert Makombe Lead PartnerFHI 360

Challenge TB implementation in Mozambique is led by FHI 360 with KNCV as a partner.

The project is implemented in four high TB burden provinces of Zambézia, Nampula, Sofala and Tete, covering 64 districts, more than 50% of the total country population. The provinces were identified by the Mozambique National TB Program (NTP) and the implementation strategy will be tailored to respond to province/district specific challenges, though Community Based DOTS Strategy (CB-DOTS) will be the core activity in each province. The project target population/key groups include People Living with HIV (PLHIV) un-enrolled, enrolled in pre-ART and/or not receiving IPT/ART, prisoners, children under five years, mining communities, Health Care Workers and the general population especially rural communities where CB-DOTS will be implemented.

The project will increase demand for TB services by implementing various activities at community level (CB-DOTS, monthly cough days etc.) and health facility enhanced active case finding strategies (FAST and clinical screening trainings) and the response to the increase in demand will be the strengthening TB prevention, diagnosis and treatment services at all levels (peripheral, district, provincial and central).

Namibia

Country DirectorAbbas Zezai Lead PartnerKNCV

Challenge TB in Namibia will commence on 1st July 2015, immediately after the close-out of TB CARE I. The work-plan development process has already begun with consultations with the USAID local mission, the Ministry of Health and Social Services and other key stakeholders and will be concluded in mid-July 2015. The key interventions will be implemented in 7 priority regions and will have a TB/HIV bias as opposed to its predecessor which was broad-based and mainly focused on national level technical assistance. The seven priority regions of Namibia include; Oshana, Ohangwena, Omusati, Oshikoto, Kavango, Windhoek and Zambezi. These were selected on the basis of having a huge HIV and TB/HIV burden.

Nigeria

Country DirectorBassey Nsa Lead PartnerKNCV

Challenge TB in Nigeria is 16 month USAID funded program with the focus to concentrate activities in 12 priority states with focused support to strengthen national-level systems. The project is designed in alignment with the National TB Strategic Plan for 2014-2020 to ensure state-specific interventions with the aim of providing universal access to TB diagnosis and treatment through strategic expansion of services. Challenge TB will focus on quality, evidence-based planning in collaboration with state teams with an emphasis on actions that produce the desired results (case notification and treatment success). Challenge TB will co locate with Global Fund (GF) to work in 6 priority states with the highest burden of TB: Akwa Ibom, Bauchi, Kano, Katsina, Lagos and Rivers and in 6 other states: Benue, Cross River, Enugu, Niger, Ondo and Osun.

The five priority issues for Challenge TB prevention and care in Nigeria include the following:

1. 1. Under-diagnosis of TB in adults and children.
2. 2. Poor treatment success in specific geographic areas.
3. 3. Inadequate integration of TB and HIV services.
4. 4. Inadequate capacity to diagnose and treat drug-resistant TB (DR-TB).
5. 5. Sub-optimal program management, human resources, data management and supply systems that are unable to support efficient scale-up of services.

Through guided evidence, Challenge TB will work to expand diagnostic and treatment services across the 12 states. The project will expand diagnostic and treatment sites strategically to increase coverage in high-volume or underserved areas, again based on mapping of existing sites versus population to determine optimal placement. Given the low level of awareness about TB and TB services, Challenge TB will develop targeted awareness-raising and outreach for the community and expand community-friendly services. In addition, the project will work to Increase capacity of providers to identify persons with presumed TB and refer for diagnosis. Working with the pediatric association, the project will support roll-out of the national pediatric guidelines and mentoring in up to five high-volume pediatric centers in states with a low proportion of diagnosed childhood TB cases.

Tanzania

Country DirectorVishnu Matungwa Mahamba Lead PartnerKNCV

The Challenge TB project in Tanzania builds on the foundations laid by the previous project (Task Order TB2015 implemented by PATH) and the USAID/Tanzania Country Development Cooperation Strategy (October 3, 2014 – October 3, 2019): Empowering Women and Youth, Tanzania’s Socio-Economic Transformation toward Middle Income Status by 2025 Advanced.

Zambia

Country DirectorMwendaweli Maboshe Lead PartnerFHI 360

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Zimbabwe

Country DirectorChristopher Zishiri Lead PartnerThe Union

Zimbabwe is one of the 22 high-burden countries for TB, with a disproportionate burden of TB/HIV co-infection as high as 69% in 2013. Through this grant, Zimbabwe seeks to consolidate the gains made over the past decade while addressing strategic gaps and priorities for TB control through the following:

Bangladesh

Country DirectorOscar Cordon Lead PartnerMSH

Bangladesh (160 million population) is both a high TB and a high MDR-TB burden country in the South East Asian region. The epidemic of TB in Bangladesh is generalized: prevalence is estimated at (402/100,000 population). Case finding is low, with only 190,000 cases notified each year, just over half of the estimated incidence. 1.4% of all new TB cases and 29% among retreatment cases are estimated to be drug resistant. Each year around 70,000 people die of TB. A prevalence survey is currently underway, with results expected in 2016. HIV prevalence is low in Bangladesh (less than 0.1%).

Challenge TB in Bangladesh is a 5 year USAID funded project supporting the National TB Program (NTP) with implementation of the national strategic plan for TB through ensuring technical leadership. The project helps the NTP in making strategic choices for a sustainable difference, ensuring the highest impact with limited resources.

Challenge TB Bangladesh is implemented by Management Sciences for Health (MSH) with the technical support from Interactive Research and Development (IRD). The overall aim of the project is to implement a broad range of sustainable interventions.

The Challenge TB framework is in line with the National Strategic Plan for TB control. The objectives of the project include:

1. 1. Improve access to quality patient-centered care for TB, TB/HIV and MDR-TB services through increased case finding, strengthening PPM and community engagement in TB, strategy/policy development and reinforcing supervisory capacity of NTP and partners.
2. 2. Strengthen the PMDT system through interventions addressing improved detection of DR TB cases, expansion of community based PMDT and support to the mHealth system.
3. 3. Strengthen the laboratory network including the development of a Laboratory Strategic Plan, improvement of External Quality Assessment (EQA) of smear microscopy, planning of accreditation of the NTRL, and maintenance of 14 safety cabinets of four reference laboratories.
4. 4. Support operations research including the support for operations research on the nine month MDR-TB regimen and the development of a national research agenda.

Challenge TB works throughout Bangladesh. The package includes all relevant components of TB control including laboratory network strengthening, PPM, PMDT, and surveillance. In addition to the nation-wide support, Challenge TB Bangladesh provides grants to local NGOs to increase case finding among key populations in specific areas and sectors, including urban slums, garment workers, tea gardens, and areas with high levels of returning migrant workers as well as high risk populations such as diabetic patients and children. Special attention is being given to children with TB, diabetics and workers in the readymade garment industries.A special feature of the project is the installation of a container based laboratory for increased access to diagnostic MDR-TB services in the Sylhet division.

Cambodia

Country DirectorSong Ngak Lead PartnerFHI 360

Cambodia is one of the 22 countries in the world with a high burden of TB. The prevalence, incidence and mortality rates of TB in 2012 were 764, 411, and 63 per 100,000 population respectively. Cambodia’s mortality rate for TB is the highest among these 22 countries, while the prevalence rate is the second-highest. There have been two national TB prevalence surveys conducted in Cambodia, in 2002 and 2011. These surveys showed a decline of 38% among smear positive prevalence rate (4.2% annual reduction) between 2002 and 2011. The surveys also showed a decline of 45% among bacteriologically positive prevalence rate or 5% annual reduction. The MDR-TB rate rose from ~10.5% in 2006 to ~15% in 2013 among retreatment cases. The MDR-TB rate among new cases was 1.4%, as last measured in the Drug Resistance Surveillance in 2006-2007.

Approximately 80% of the population in Cambodia is registered as rural, and both TB prevalence surveys found geographic variations between urban and rural clusters. Elderly people had smear-positive TB prevalence rate of ~1,000 cases per 100,000 population and bacteriologically-positive TB prevalence rate of ~3,000 cases per 100,000 population. These are about four times that of the general population. The proportion of smear-positive TB among bacteriologically positive TB was higher in rural areas than in urban areas (35% vs 23%).

Challenge TB Cambodia is led by FHI 360, collaborating with two in-country coalition partners (MSH and WHO). The project is assisted through short-term technical assistance from three collaborating partners. It is a 5 year USAID funded project supporting the National TB Program (NTP) with implementation of the national strategic plan for TB 2014 - 2020. The project will help the NTP make strategic and informed choices based on proven best practice for a sustainable difference, ensuring the highest impact with limited resources.

The Challenge TB five year framework is in line with the National Strategic Plan for TB control and country programmatic and geographic gap. The core priority components of the National TB Program presenting in three main pillars of intervention as below:

1. 1. TB care and prevention: to scale up high quality integrated patient-centered TB care and prevention and respond to priority challenges to TB control including prisoners, PLHIV, pregnant women and children, contacts, diabetics, elderly, internal and external migrants as well as indigenous populations in order to achieve universal access for all patients.
2. 2. Policies and supportive systems: to provide strong leadership with clear policies and supportive systems including monitoring and evaluation, strong partnerships necessary to expand TB control, contribute to health and community systems strengthening, resource mobilization, and ensure adequate and competent human resources for TB control.
3. 3. Intensified research and innovation: to promote the use of new diagnostic tools, interventions and strategies; and enhance operational research and innovation to generate evidence for policy formulation and implementation.

Challenge TB provides technical assistance to all levels of the health care system, to improve clinical diagnosis and treatment and implementation of new intervention approaches to find the missing TB cases. At central level, Challenge TB will provide technical assistance to ensure quality of diagnostic tools and guideline development and standardization of interventions across all partners.

Challenge TB Cambodia will also provide support to the Country Coordinating Committee and also a board members of National Center for Tuberculosis and Leprosy Control (CENAT), a Principal Recipients (PR) of Global Fund Against AIDS, TB and Malaria. Challenge TB will assist the PR’s to monitoring the progress of the program, address specific technical and managerial issues, and support in planning and implementation. USAID/ Challenge TB Support is complementary to Global Fund assistance.

India

Country DirectorImran Syed Lead PartnerThe Union

The Revised National TB Control Program (RNTCP) has made significant achievements since its inception including attainment of the TB-related targets of the Millennium Development Goal well ahead of time. However, challenges remain – India continues to carry the highest TB burden in the world, around one million cases are both missed and not notified to national programme, mortality continues to remain high and the emerging challenge of drug resistance TB threatens to undo the gains made so far. To address these, the RNTCP, with support from its technical partners, prepared an ambitious “fast track plan” to accelerate activities aimed at achieving demonstrable progress toward the Country’s vision of “TB Free India”. Understandably, addressing a public health issue of this magnitude requires intensified and collaborative efforts from all stakeholders in the country and beyond.

Challenge TB India is a two-year USAID funded project primarily designed to implement a Call to Action for TB Free India. The project is led by The International Union Against Tuberculosis and Lung Disease (The Union) and assisted through short-term technical assistance from KNCV. It is implemented under the stewardship of the Ministry of Health and Family Welfare in India.

The goal of Challenge TB India is to create and sustain high-level domestic commitment through mobilization of a wide range of stakeholders to provide a momentum capable of demanding and sustaining high-level domestic commitment to end TB in India. Challenge TB will tap the energy and influence of key stakeholders to drive engagement of the private sector, civil society, media, and public representatives to bring them on a common platform for a call to action to end TB.

The 'Call to Action' has kick started and catalysed the Government of India's efforts to accelerate TB prevention and care in partnership with all stakeholders. The Call to Action aims to unite existing and new stakeholders in the fight against TB and bring together knowledge, resources and capacity. A key part of the campaign will be to create new partnerships, perhaps sometimes where they are unexpected.

Indonesia

Country DirectorErik Post Lead PartnerKNCV

Indonesia (Population: 250 million) is both a high TB and a high HIV burden country with the fastest growing (mainly concentrated) HIV epidemic in the region. The epidemic of TB in Indonesia is generalized: the latest TB prevalence survey (2014) revealed the prevalence 2.5 times higher than previously estimated (average 660/100.000 population). The estimated incidence is more than 1 million new cases / year, however only 327,103 TB cases were notified in 2013. 2% of all new TB cases and 12% among retreatment cases are estimated to be drug resistant. Each year around 100,000 people die of TB.

The Challenge TB 5 year framework is in line with the National Strategic Plan for TB control. The plan addresses the major gaps of the National TB Program, prioritizing five technical intervention areas:

1. 1. Ensuring Universal Access by integrating TB in the National Health Insurance System (JKN), and securing increased local government funding for TB.
2. 2. Increasing case detection: Intensified Case Finding to address the current gap in notification.
3. 3. Ensuring the quality of treatment and care for TB, Drug resistant TB and TB/HIV co-infection.
4. 4. Expanding the network of diagnostic services.
5. 5. Strengthening M&E, surveillance and operations research.

At national level Challenge TB provides Technical Assistance (TA) to the Directorate of CDC within the Ministry of Health as the main beneficiary / partner. Additional recipients of TA include other Government Institutes (such as Medical Services, Laboratory and Pharmaceutical Services), provincial and district health offices, professional societies, community organizations and other local partners in all supported provinces.

Challenge TB works in nine provinces: Five of these provinces (Jakarta, West Java, Central Java, East Java, and North Sumatra) are prioritized and receive intensified assistance in 10 priority districts, supporting down to selected (sub) district level. The aim is to design "best models", testing these through small-scale implementation at district level, with a view to scaling up these best models both within these provinces and more broadly. The intensified package includes all components of TB control including laboratory network strengthening, PPM, PMDT, TB/HIV and surveillance.

Additionally Challenge TB provides technical support to 4 other provinces (Papua, West Papua, West Sumatra and South Sulawesi). The focus in these provinces are on expansion and quality assurance of essential components of TB control including laboratory, TB/HIV, PMDT expansion and intensified TB case finding. Local health services and partners in these provinces will receive a more ‘’specified package’’ of technical assistance based on their needs.

Challenge TB Indonesia will also provide support to the principal recipients of Global Fund TB. As a Sub Recipient, KNCV will assist the recipients to address specific technical and managerial issues, and support in planning, implementation and troubleshooting. USAID/Challenge TB Support is complementary to Global Fund assistance.

Burma

Country DirectorSaung Oo Zarni Lead PartnerFHI 360

Burma is one of the 41 high TB/HIV burden countries, with one of the most severe HIV/AIDS epidemics in Asia. The HIV prevalence in the general adult population has declined over the past five years from 0.6% in 2010 to 0.5% in 2013. However, according to HIV Sentinel Surveillance data collected in 2013, there was a concentrated HIV epidemic among key affected populations including people who inject drugs (18.7%), men who have sex with men (10.4%), new TB patients (9.2%) and sex workers (8.1%). The number of new infections among adults over 15 years in 2013 was 7,097.

Challenge TB in Burma is a 5 year project designed to address low case detection, limited access to quality assured laboratory diagnostic services, and low MDR-TB treatment capacity.

The Challenge TB framework is in line with the National Strategic Plan for TB control. The objectives of the project include:

1. 1. Reaching the hard-to-reach
2. 2. Strengthening the laboratory network
3. 3. Strengthening NTP in analysis of and strategic planning for novel intervention strategies

Vietnam

Country DirectorHuong Nguyen Lead PartnerKNCV

Viet Nam ranks 12th among the top 22 countries with the highest TB burden in the world and 14th among the 27 countries with the highest TB multi drug resistance burden worldwide (WHO report 2014). WHO estimated the annual reduction of TB prevalence and incidence in Viet Nam for 1990-2010 as 4.6% and 2.6% respectively. WHO estimated that the TB-related mortality dropped from 1990 to 2010 by about 4.4% per year. Compared to 1990, the TB prevalence and mortality in Viet Nam have dropped by about 62% and 60% respectively.

The overall strategy of Challenge TB in Viet Nam is to develop, pilot and evaluate TB care and prevention innovations that are planned under the National Strategic Plan 2015-2020, in close collaboration with the NTP, VAAC, the USAID Mission and partners. After evaluation and ensuring adjustments, the innovations will be mainstreamed by the NTP with domestic and other donor (mainly GF) resources. This approach was shown to be effective during TB CAP and TB CARE I implementation. In this way Challenge TB investments will leverage other resources, while spearheading program innovation. Challenge TB will also ensure effective use of Global Fund investments, by providing technical assistance to the rollout of the innovations. Evidence will be collected to document the operational processes and their impact.

1. 1. Enabling environment
2. 2. Comprehensive high quality diagnostic network
3. 3. Patient-centered care and treatment
4. 4. Infection control
5. 5. Political commitment and leadership
6. 6. Comprehensive partnerships and informed community involvement
7. 7. Quality data, surveillance and M&E
8. 8. Human resource development
9. 9. Overall technical supervision.

Several activities of Challenge TB have benefited all 63 provinces across the nation; however, the key focus of the project in the first year was primarily on 15 Provinces; 4 high TB/HIV prevalence provinces, 9 MDR-TB treatment centers, and two PMDT satellite provinces. With this coverage, Challenge TB has supported 38.6 million people in 3,232 communes of 193 districts, an equivalent of 39% Viet Nam’s total population (2013). Additionally, Challenge TB continued its support for access to the WHO-approved rapid diagnostic platforms (GeneXpert) in all 45 provinces within the framework of the PMDT of National Tuberculosis Control Program.

Afghanistan

Country DirectorMohammad Khakerah Rashidi Lead PartnerMSH

Afghanistan ranks as one of 22 high TB burden countries. The estimated incidence of TB all forms is 189 per 100,000 population per year, and the prevalence of all forms of TB was estimated at 340 per 100,000 population. Annually, there are approximately 58,000 new TB cases in the country, the existing numbers of cases are estimated to be 100,000, and an estimated 13,000 Afghans die of TB every year.

In 2014, the National Tuberculosis Control Program (NTP) was able to notify 31,746 new TB cases (all forms) which is only 55% of all estimated TB cases in that year. The treatment success rate for all TB cases was 88% and for new bacteriologically confirmed TB cases it was 90%.

The Challenge TB project in Afghanistan is led by MSH and KNCV is the coalition partner will have local partnership with BPHS NGOs for its implementation. Challenge TB will focus on helping the NTP maximize its outcomes through these technical areas; Strengthening leadership and management for TB control focus on provincial level, Increasing TB case notification and improving quality of care strengthening M&E, surveillance and operations researches, expansion of urban DOTS and community based DOTS, implementing TB infection control and strengthening health systems.

The main aim of the Challenge TB Afghanistan project is to assist the NTP to reach its strategic objective of increasing TB case notifications by at least 6% annually through provision of quality TB services to the needy communities countrywide.

To enhance the leadership and stewardship role of the NTP team and NGOs, Challenge TB will improve the governance and coordination of TB service delivery at provincial and local levels. As a result the NTP will be able to develop and apply tools and approaches that will improve its leadership and management capacity. Ultimately, decentralization and multi-sectorial partnership at provincial level must address NTP’s strategic programmatic gap of low TB case notification and maintain the treatment success rate.

Kazakhstan

Country DirectorName Lead PartnerKNCV

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Kyrgyzstan

Country DirectorBakyt Myrzaliev Lead PartnerKNCV

Kyrgyzstan is among the 27 countries in the world with a high burden of MDR-TB and 18 high-priority countries for TB in the WHO European Region.

The overall goal of the Challenge TB project in Kyrgyzstan is to reduce the TB burden in Kyrgyzstan by improved management of pre- XDR, XDR-TB and other complicated forms of MDR-TB.

Based on the National Strategic Plan and taking into consideration the partners’ activities in the country, Challenge TB will provide technical assistance to the national TB program in the preparation and implementation of new drugs and treatment regimens in the context of the national situation. KNCV will help the country to set up the essential treatment and management conditions for the use of new drugs and treatments, while at the same time developing measures to care for and to prevent community transmission from patients for whom no effective treatment is yet available.

Tajikistan

Country DirectorMavluda Makhmudova Lead PartnerKNCV

TB re-emerged as an important public health threat after the breakdown of the Soviet Union, and its burden remains high in Tajikistan. According to the World Health Organization, the estimated TB incidence was 100 per 100,000 populations in 2013, which is the fifth highest level of TB burden among 53 countries of the WHO European Region. The estimated TB mortality rate (excluding TB/HIV cases) in 2013 was 6.9 per 100,000 population. According to the national TB program notifications data, a total of 6,495 TB cases (79.2 per 100,000 population) all forms, were registered in the country in 2013 (including penitentiary sector); and out of these, 5,306 were new cases (70.0 per 100,000). The high burden of anti-TB drug resistance is one of the key challenges in Tajikistan.

According to the NSP, over next six years, about 42,870 all forms TB cases, will need anti-TB treatment in Tajikistan. Out of these, over 5,840 cases are expected to have advanced drug resistance (M/XDR-TB) and thus will require second-line and third-line TB drugs. The national strategic plan aims to reach universal treatment coverage for MDR-TB (including XDR-TB) by the year 2020 (i.e. coverage of at least 90-95% of the estimated total need).

The Challenge TB project has identified as the main priority the introduction of shortened regimens and regimens containing new drugs (including adequate PV). The vast majority of MDR-TB patients (approximately 85%) without additional resistance to key SLDs would be eligible for shortened treatment regimen. For the remaining cases with wider resistance (pre-XDR, XDR-TB) regimens containing group 5 (including new TB drugs such as bedaquiline and delamanid) should be urgently introduced to improve treatment success rates among this group and to stop XDR-TB transmission. Within the project, special emphasis will be paid to improvement of the pharmacovigilance system for anti-TB drugs, as part of the overall pharmacovigilance system in the country. For introduction of new drugs and regimens, WHO requires active pharmacovigilance. Therefore, in addition to reinforcing spontaneous reporting by health care institutions and providers involved in the management of TB cases, KNCV will incorporate active pharmacovigilance into the MDR-TB treatment program. This will allow not only for effective post-marketing surveillance of the medicines, but it will also strengthen the NTP’s capacity to improve the management of adverse drug reactions, thus reducing the risks of treatment interruption and failure because of these reactions.

In this regard, the overall strategy of the Challenge TB project in Tajikistan is to improve quality of care for patients with MDR-TB through building the NTP’s capacity for management and implementation of shorter treatment regimens and new TB drugs.
 
In order to carry out this strategy, KNCV, through the Challenge TB project, will focus on following activities:

• Creating appropriate conditions for the implementation of a shortened treatment regimen Assessment of current MDR-TB management
• Development of plan for introduction shortened regimens and new drugs.
• Building capacity of the NTP on management of patients enrolled on new treatment regimens.
• Adjustment of diagnostic algorithms.
• Development of clinical protocols.
• Supportive supervision and monitoring of case management.

Eastern Europe

Ukraine

Country DirectorKatya Gamazina Lead PartnerPATH

The goal of the first year Challenge TB Project in Ukraine is to improve MDR-TB services and outcomes for MDR-TB patients in partner Mykolaivska and Poltavska oblasts through the integration of a patient-centered approach based on the ambulatory health care system into oblasts’ routine MDR-TB case management system, resulted in reducing mortality, lowering default rates, improving MDR-TB case detection and diagnosis, and enhancing treatment success. The lead partner of Challenge TB in Ukraine is PATH in partnership with KNCV.

Project Objectives:
Improve enabling environment through developing and piloting a model of ambulatory care for MDR-TB patients based on a patient-centered approach considering different local conditions (rural vs. urban, special populations, etc.) and different patient's preferences to maximize the benefits to the MDR-TB patient and minimize the costs to both the patient and the health care system. During Year 1, Operations research on the cost of MDR-TB treatment based on different models will be conducted.

Ensure patient-centered care and treatment through advocating to Health Care authorities in project sites for expanding TB services to ambulatory primary health care, emphasizing the advantages of ambulatory care which include a decrease in the costs related to hospitalization, reduction in the risk of ongoing TB transmission to other patients and healthcare staff within facilities, and an increase in patient autonomy and satisfaction that will lead to greater completion of treatment and decreases in loss to follow up.

During Year 1, the Project will:

• Assist in the design of a desired model of collaboration and mobilize available resources for building a patient-centered health care system at the ambulatory level.
• Ensure assessment of the each patient’s needs and linkage to other support services as needed especially for MDR-TB patients co-infected with HIV, alcohol or drug users, released prisoners, homeless and others.
• Identify and implement mechanisms for ongoing patient support to address conditions that threaten their ability to complete treatment through the involvement of Red Cross visiting nurses, HIV service organizations, and other social resources.
• Test the possibility of volunteer services at the community level to support treatment completion and ensure DOT at ambulatory stage.
• Assist in establishing an on-the-job supervision system in partner oblasts.
• Help oblasts to improve the quality of laboratory diagnosis of MDR-TB cases and to strengthen its capacity in monitoring and evaluation of MDR-TB program implementation.

Strengthening infection control to ensure compliance with proper infection control (IC) measures in all health care settings and community, providing assistance in project oblasts in development of the oblast IC plans, and revising the oblast TB hospitals’ IC plans.

Enhancing political commitment and leadership to ensure sustainability of effective TB-related interventions at the national and oblast levels, the project seeks to enable the government of Ukraine to make critical, technically sound policy and program decisions to improve MDR-TB control in accordance with international best practices, providing technical assistance to the WHO national TB program review and development of the next national TB strategic plan (Program) for 2017 – 2021. The Project will assist with the development of the national MDR/XDR-TB Scale-Up Plan and national guidelines on side-effects management.

Addressing human resource development and strengthening the capacity of providers at the oblast level in MDR-TB case management, including in people with HIV comorbidity, through a number of trainings and a study tour to the WHO MDR-TB Collaborative Center in Riga (Latvia).