Two high-profile initiatives were launched late last year, each designed to shore up the response to the global tuberculosis epidemic.
The World Health Organization (WHO) estimates that 10.4 million people fell ill with the disease in 2015, including 480,000 patients with multidrug-resistant (MDR) TB. An estimated 1.8 million people died from TB that year, which includes 400,000 deaths from TB disease among people living with HIV. That makes it the world’s leading infectious killer.
Of the $800 million for catalytic investments the Global Fund Board approved at its November Board meeting (see GFO article), $125 million is allocated for TB case finding. This comes on top of core individual country allocations dedicated to case finding.
Meanwhile, in December the United Nations General Assembly (UNGA) agreed to hold a high-level meeting in 2018 on TB to build on existing efforts to end the epidemic.
“We need to push the countries to really think beyond the usual things they to do find more of the people that are affected by TB,” Dr Lucica Ditiu, Executive Director of the Stop TB Partnership, told Aidspan.
The Global Fund’s catalytic investments, which will build on 2017-2019 grant cycle allocations, are designed to fall in line with a new six-year strategy (see GFO article) the Global Fund Board adopted last year. Among the strategic goals is a commitment to maximize impact in the fight against HIV, TB and malaria.
Dr Ditiu said finding missing TB cases and starting them on treatment is one of the best ways to maximize impact. This is especially true for patients with MDR-TB, which is both expensive and difficult to treat.
“Without finding these cases and being able to diagnose them properly and put them on treatment and get them proper care, we will not be able to stop anything,” she stated further. But the overall number of unidentified or unreported cases has actually grown since 2013, when it was three million, according to the WHO and the body, in its report, states only one out of every four patients with MDR-TB was diagnosed as of 2012. “It’s a black hole that is not shrinking, but expanding.”
Though the reasons for the gaps in case detection vary by country, she said many patients face barriers to entering the health system, whether it is distance, cost or – for marginalized groups – stigma.
The Global Fund, in collaboration with partners that included the Stop TB Partnership determined a significant amount of the catalytic investments dedicated to TB should be used to help countries introduce and scale up a package of services that are based on principles of searching, finding, diagnosing and treating all forms of TB and preventing the spread of the disease.
This package, which will ultimately be tailored to individual countries, includes systematic screening – especially for MDR-TB, higher distribution of cutting-edge diagnostic technology, better engagement of the private sector, which is where many TB patients seek services and improvements in surveying and collecting data on case finding and treatment.
The Global Fund will use two different approaches to channel money into case finding. In the first, the Global Fund allocated $115 million in matching funds for programs in high-burden, high-impact countries. Money will ultimately go to between five and ten of the countries where 70 to 80% of the missed TB and MDR-TB cases are estimated to live, according to the Global Fund’s Catalytic Investments Report. Those countries are India, Indonesia, Nigeria, Pakistan, South Africa, Bangladesh, the Democratic Republic of the Congo, Tanzania, Ukraine, Myanmar and the Philippines.
The Fund also earmarked $7 million from its strategic initiatives within the catalytic investments to address specific barriers to finding missing TB cases, especially in key populations, and an additional $3 million for the development of community and innovative approaches to accelerating case finding.
Dr Ditiu said there are communities, whether because of their gender, sexual orientation or poverty status, where it has been traditionally difficult to find cases. And she urged the Global Fund to use the money for strategic initiatives to pay for innovative strategies for identifying cases in these hard-to-reach populations.
“The Global Fund may need to have an increased appetite for risk in the disbursement and use of these funds,” she said. “They cannot be raising eyebrows if people are proposing interventions that don’t seem so orthodox, otherwise the catalytic funds might not have so much impact.”
Some of the strategic initiative funding is also slated for policy development and advocacy and the dissemination of information, according to the Catalytic Investments Report.
A third form of catalytic funding – financing multi-country approaches – also includes $65 million for multi-country TB interventions, though it does not necessarily include case finding.
Meanwhile, Dr Ditiu said she expects the UNGA high-level meeting to “bring to light the need for political and financial support of both TB implementation and scale up – including on missed cases of TB and drug-resistant TB – but also the huge need for new tools and investments in research and development for TB.”
Past high-level meetings have been policy-oriented, helping set a framework that national leaders and ministers of health can introduce in their own countries.
The UNGA adopted the resolution to hold the meeting following a campaign led by South African Health Minister Dr Aaron Motsoaledi, who is also the chair of the Stop TB Partnership board. After the campaign was launched in September 2016, Stop TB and its partners lobbied governments to support the effort. Ultimately, a key UN country grouping, the Global Health and Foreign Policy Initiative, tabled the idea in front of the General Assembly in December, where it was adopted.
Mario Raviglione, the director of the WHO’s Global TB Program, said his team is already involved in discussions about the agenda for the meeting and among the issues he expects to see raised are developing multi-sectoral responses to TB, integrating MDR-TB into the agenda for monitoring and combating anti-microbial resistance and ensuring the rapid delivery of the latest technology.
The UNGA high-level meeting is set to follow a November 2017 global ministerial conference in Moscow on TB within the context of the Sustainable Development Goals. Raviglione said the idea for the 2018 high-level meeting grew in part from this conference, with the idea that it could help draw more attention to – and more financing for – the recommendations that emerge from Moscow.
“There is a need for global leadership,” he said. “TB is not a disease you can face only from the health perspective.”