Technical Assistance to (TB) TB/HIV Prevention and Control in Ethiopia

Ethiopia ranks as seventh among the 22 highest burden tuberculosis (TB) countries in the world according

to the 2007 World Health Organization (WHO) Global TB Report. It is a leading cause of morbidity and

mortality, and since the disease strikes people during their economically productive years, it represents an

important development challenge. Pulmonary TB (PTB) is the third leading cause of hospital admission and

second leading cause of death. The estimated incidence of all forms of TB and smear-positive PTB (PTB+)

was 341 and 152 per 100,000 populations, respectively. The case detection rate of PTB+ cases was 33%,

less than half the global target of 70%. The burden of HIV/AIDS is also significant. Ethiopia's national adult

single-point HIV prevalence for 2007 was estimated at 2.1%, with a 7.7% urban rate and a 0.9% rural rate.

Adult (15-49 years) deaths due to AIDS accounts for about a quarter of all young adult deaths in the

country.

HIV prevalence studies among a representative group of TB patients have not been carried out. The HIV

prevalence among TB patients is considerably higher than in the general population, and varies by area.

According to data from hospitals and health facilities implementing TB/HIV collaborative activities, including

provider-initiated counselling and testing (PICT) of TB patients, 41-70% of TB patients are HIV-positive in

these sites.

The presence of extremely drug-resistant TB (XDR TB) and multidrug-resistant TB (MDR TB) raises the

concern of a future drug-resistant TB epidemic with restricted treatment options that will jeopardize the

major gains made in TB control and progress on reducing TB death among persons living with HIV/AIDS

(PLWH). WHO, in 2007, estimated that 420,000 new MDR TB cases occur each year as a result of

underinvestment in basic TB control, mismanagement of anti-TB drugs, transmission of drug-resistant

strains, problems in drug supplies, limited laboratory capacity, and the health workforce crisis.

The XDR TB and MDR TB situation in Ethiopia, and the extent to which they are related to HIV, is not well-

understood. With an estimated 5,102 MDR cases, Ethiopia ranks 12th in the world in terms of estimated

burden of MDR TB. In 2007, WHO estimated that among TB cases, 1.7% are MDR, and among previously

treated cases, 8% are MDR. The proportion of XDR is not known. Patients who fail to respond to first-line

treatment, or patients who relapse, are put on a re-treatment regimen. Although there is now country-wide

notification, there are a large number of patients who fail re-treatment. At St. Peters hospital in Addis Ababa

in 2007, of 130 MDR patients who failed re-treatment, 50% are resistant to four drugs and 35% to three. As

second-line treatment for these patients is not available in Ethiopia, they are consequently sent home,

risking infecting others. Only the few who can afford to buy drugs from abroad can be put on second-line

treatment. WHO estimates that Ethiopia will need to treat 343 MDR and 34 XDR TB patients in 2007, and

669 MDR patients and 61 XDR TB patients in 2008.

Ethiopia established a TB/HIV Advisory Committee (THAC) in 2002. THAC is comprised of key

stakeholders from the TB and HIV/AIDS programs, major multi- and bilateral donor organizations, research

institutions, academic institutions, and professional associations. THAC provides technical and policy

guidance to the Federal Ministry of Health (MOH) and other partners, and it established a TB/HIV technical

working group in 2007. The group chair alternates on an annual basis between the director of the National

TB and Leprosy Control Program (NTLCP) and the director of the HIV/AIDS Prevention and Control Office

(HAPCO).

Ethiopia's TB/HIV program has benefited recently from increased resources for TB/HIV collaborative

activities, with support from the USG, WHO, German Leprosy and TB Relief Association (GLRA), and Italian

Cooperation. In addition, in 2006 Ethiopia was awarded a Global Fund for AIDS, TB and Malaria (Global

Fund) Round 6 grant for TB. The TB/HIV collaborative activities have now expanded to almost 300 health

facilities in the country, including 98 USG-supported ART hospitals and nearly 200 USG-supported health

centers.

In FY07, the USG allocated $4,650,000 in "plus-up" funding for TB/HIV collaborative activities in Ethiopia,

but gaps still remain, especially in the presence of XDR and MDR TB. In July 2007, PEPFAR Ethiopia

asked a team from the USG TB Control Assistance Program (TBCAP) to undertake an assessment of

Ethiopia's collaborative activities. The review included review of the FY07 plus-up work plan, the Global

Fund's Round 6 proposal, and the 2007-2008 XDR and MDR TB Global Response Plan. The assessment

led to recommendations for the USG to focus on the following three key program components in FY08:

Component One: Strengthen TB/HIV management and leadership capacity:

1) Provide high-level technical and financial support to strengthen the national TB/HIV technical working

group, including supporting the finalization of the group's expected outputs, such as policy and guideline

development

2) Strengthen TB/HIV leadership, through long- and short-term technical assistance (TA), to 2-3 regional

health bureaus (RHB) with low rates of TB case-finding and treatment outcome, to improve TB/HIV

coordination, collaboration and supervision. The regions with the highest population and greatest need will

receive priority: Oromiya, Amhara, Southern Nations, Nationalities and Peoples regions (SNNPR), and

Addis Ababa. The four regions hold 85% of Ethiopia's total population.

3) Strengthen advocacy and communication on TB/HIV and XDR and MDR TB among policy makers and

healthcare management at different levels

4) Strengthen analytical and presentation skills among the TB staff for managerial and advocacy purposes

5) Increase the capacity of HIV/AIDS staff to undertake TB control at various levels of the health system, at

the national level and in 2-3 regions

Component Two: Strengthen XDR and MDR TB management, particularly of TB/HIV co- infected patients,

in line with the Global Response Plan 2007-2008. The USG will provide technical and financial support to

ensure effective and efficient implementation of the recommendations made by the MDR Task Force

established under the FY07 TBCAP work plan to assist Ethiopia in reaching the targets set by the Global

Plan to Stop TB, and the Global MDR TB and XDR TB Response Plan 2007-2008. The USG support will

build on the results of activities already planned in FY07 and will focus on:

1) Strengthening the management of MDR TB by training National TB Program (NTP) staff at national

regional levels through study tours, workshops, and conferences

Activity Narrative: 2) Assisting the NTP with developing, disseminating, and beginning implementation of the MDR guidelines

on scaling up program management on XDR and MDR TB, particularly in co-infected patients. This would

include expanding MDR TB treatment sites and helping Ethiopia to obtain "Green Light Committee"

approval from the WHO/Geneva/Stop TB Program for approval and renovation of facilities at those sites.

3) Developing and beginning implementation of a national infection-control strategy, including training at all

levels

4) Strengthening the lab referral network between TB/HIV and XDR and MDR TB services

Component Three: Strengthen the monitoring and evaluation (M&E) system of TB/HIV and XDR and MDR

TB. The USG will provide technical assistance to strengthen the existing M&E system for TB/HIV and XDR

and MDR TB, as follows:

1) Provide technical assistance to TB/HIV, XDR and MDR TB M&E systems to strengthen analytical skills in

M&E and data collection and use among NTP staff at different levels, and to strengthen presentation skills

among the TB staff on data management

2) Assist the NTP to monitor the extent and effectiveness of cotrimoxazole preventive therapy in TB/HIV co-

infected patients

3) Build on the efforts of the Government of Ethiopia and other partners' efforts at the national level. Work

with all relevant stakeholders and implementing partners to train regional and district TB/HIV management

staff on data management, including analysis and use.

4) Where appropriate, procure computers for selected sites to strengthen site-level capacity to analyze and

use TB/HIV data.

The end result of this activity will be to decrease the burden of TB among people living with HIV/AIDS

(PLWH) and the general population through strengthening the TB/HIV collaborative initiative in Ethiopia.

The targeted population is PLWH and persons living with TB/HIV, TB suspects, and patients, the NTP staff

and healthcare workers at the lower levels. In addition, the general population will be an indirect beneficiary,

because the burden of infectious TB will be reduced.

Activities will be implemented in a collaborative and coordinated manner with other partners working on

control of TB and TB/HIV. The activity will leverage a wraparound of an estimated $500,000 in FY08 non-

PEPFAR USG TB funding for TB control and management, and will link closely with work by other PEPFAR

partners working on TB/HIV, including the Ethiopian Health and Nutrition Research Institute (ID 11157 and

12314), Abt Associates Private Sector Program (ID 10375), WHO (ID 12316), the four PEPFAR-supported

US universities working in HIV/TB (ID 10456, 10429, 10463, 10469), Management Sciences for Health/Care

and Support Program (ID 10400), HAPCO (FY07 reprogrammed PEPFAR funds), and other donors,

including the Global Fund, GLRA, Italian Cooperation, and the Dutch Government.