fighting poverty to control tb - who.int · fighting poverty to control tb ... m rivero, cm ford,...

Fighting poverty to control TB

Carlton A Evans ([email protected])

IFHAD: Innovation For Health And Development research group: Peru: Universidad Peruana Cayetano Heredia Asociacion Benefica PRISMA UK: Imperial College London USA: Johns Hopkins Bloomberg School of Public Health

DOTS Care Prevention Innovation

Policies Health

systems

People

Pathogens Smear & treat

Saved millions of lives

Revolutionised TB care

Extremely cost-effective

Model for global health

Over-emphasizes smear

Under-emphasizes MDR

Under-emphasizes people

Under-emphasizes prevention

Poverty is bigger than money

Addressing social determinants is bigger than cash transfers

0 1 4 3 2 6 5

Hazard of

Abandoning

Treatment

0

%

10

%

20

%

not

depressed

depressed

Treatment Month

C Acosta, D Boccia, R Montoya , D Onifade, C Ford, J Franco, J Alva, C Evans. TB stigmatization is associated with disease concealment and poor treatment adherence. IJTLD 2010: 14 (11);

S248. Allen, F Fernandez, C Loiselle, C Rocha, R Montoya, K Zevallos, A Curatola, C Evans Depression & suicidal tendencies in TB patients. IJTLD 2010:14;S312. M Maritz, A Bayer, K

Zevallos, CD Acosta, R Montoya, M Rivero, CM Ford, CA Evans. TB treatment adherence &mortality are predicted by low social capital. IJTLD 2011:15;S304-5

Divorcing direct observation

Supervised direct observation

(with menaces) is:

• stigmatising,

• patronising,

• disrespects social justice

• doesn’t help (Pasipanodya 2013)

Helping with the bus fare

is not social justice;

we should change to informing,

incentivising & enabling adherence

0

2

4

6

8

10

Failure Relapse Aquired-DR

Risk difference (x10) DOT incidence Self incidence

Social justice: TB pills are an inadequate response to despair

Addressing TB social determinants: why

Necessity: social protection necessary for DOTS to work:

labs & pills can only cure if access is affordable

Social protection may allow DOTS-cure to evolve into TB control

EVIDENCE:

1. PAST: wealth & poverty causes great changes in TB rates

Dye, C et al. Trends in TB incidence and their determinants in 134 countries. Bull World Health Organ 2009;87:683–691

National changes

in TB rates

are associated

with

socioeconomic

development

not control TB

programs 2. PRESENT: success of DOTS saving lives & reducing suffering

is not achieving control; social determinants still drive TB rates

3. PRINCIPLE: TB pills respond to poverty effects ~war surgery

4. PREVALANCE: most prevalent TB is not currently detected

Simplifying DOTS evolution

(DRAFT) - Proposed Pillars and Principles of the Post-2015 TB Strategy

Innovative TB Care

Bold Policies and

Supportive Systems

Intensified Research

and Innovation

Surv

eill

ance

, Mo

nit

ori

ng

an

d E

valu

atio

n

Innovative TB Care

Rapid diagnosis of TB including universal drug-susceptibility testing ; systematic screening of contacts and high-risk groups

Treatment of all forms of TB including drug -resistant TB with patient support

Collaborative TB/HIV activities and management of co-morbidities

Preventive treatment for high-risk groups and vaccination of children

Bold policies and supportive systems

Government stewardship , commitment, and adequate resources for TB care and control with monitoring and evaluation

Engagement of communities , civil society organizations, and all public and private care providers

Regulatory framework for vital registration, case notification, drug quality and rational use, and infection control

Universal Health Coverage, social protection and other measures to address social determinants of TB


Discovery, development and rapid uptake of new diagnostics, drugs and vaccines

Operational research to optimize implementation and adopt innovations

Vision: A world free of TB

(DRAFT) Post-2015 TB Strategy

GOAL TARGETS FOR 2025 Zero TB deaths (or) TB mortality rate reduced by 50% (compared with 2015) Elimination of TB deaths and suffering (or) TB prevalence rate reduced by 50% (compared with 2015) Elimination of TB as a public health problem A target on MDR-TB / TB treatment coverage (for discussion)

Care Prevention Innovation

Policies Health

systems

People



Policies Health systems Wealth Operational research

People Equitable

access

Health Trials

Pathogens Test & cure Hygiene Science

DOTS

WHO

Message

(DRAFT) - Proposed Pillars and Principles of the Post-2015 TB Strategy

Innovative TB Care

Bold Policies and

Supportive Systems


and Innovation

Surv

eill

ance

, Mo

nit

ori

ng

an

d E

valu

atio

n

Innovative TB Care

Rapid diagnosis of TB including universal drug-susceptibility testing ; systematic screening of contacts and high-risk groups

Treatment of all forms of TB including drug -resistant TB with patient support

Collaborative TB/HIV activities and management of co-morbidities

Preventive treatment for high-risk groups and vaccination of children

Bold policies and supportive systems

Government stewardship , commitment, and adequate resources for TB care and control with monitoring and evaluation

Engagement of communities , civil society organizations, and all public and private care providers

Regulatory framework for vital registration, case notification, drug quality and rational use, and infection control

Universal Health Coverage, social protection and other measures to address social determinants of TB


Discovery, development and rapid uptake of new diagnostics, drugs and vaccines

Operational research to optimize implementation and adopt innovations

Vision: A world free of TB

(DRAFT) Post-2015 TB Strategy

GOAL TARGETS FOR 2025 Zero TB deaths (or) TB mortality rate reduced by 50% (compared with 2015) Elimination of TB deaths and suffering (or) TB prevalence rate reduced by 50% (compared with 2015) Elimination of TB as a public health problem A target on MDR-TB / TB treatment coverage (for discussion)


Policies Health

systems

People



Policies Health systems Wealth Operational research

People Equitable

access

Health Trials

Pathogens Test & cure Hygiene Science

DOTS

WHO

Message

Simplifying DOTS evolution

Evidence for impact of social protection for TB

“This review

shows a lack of

studies on

microfinance and

cash transfer

interventions that

specifically ad-

dress TB or other

respiratory

infections. “

D Boccia, J Hargreaves, K Lonnroth, E Jaramillo, J Weiss, M Uplekar, JDH Porter, CA Evans. Cash transfer & microfinance

interventions for TB control: review of evidence & policy implications. IntJ TB & Lung Disease 2011: 15(6); S37-59

Social support

to facilitate TB care

Economic support

To reduce poverty

EVALUATION

Improved TB care Reduced TB risk

Reduced TB

Objective: to generate evidence

whether socio-economic interventions

can strengthen TB control

Population: TB-affected families,

living with impoverishment of TB &

risk of recurrence & transmission

‘ISIAT: Innovative Socioeconomic Interventions Against TB’ project

A Curatola, R Montoya, M Rivero, C Rocha, M Tovar, T Valencia, K Zevallos, C Evans. Fighting

poverty to control TB: preliminary results of a trial in Peru. IJTLD 2009: 13(12);S60

(c)

Social dimension Economic dimension

* Household

Visits

* Community

Workshops

Conditional food transfers &

* psychology support

* Microcredit &

Microenterprise

* Vocational

training

Community support to increase access to TB care Poverty reduction to reduce TB risk

Act

ivit

ies

Ou

tcom

es a

lon

g t

he

TB

cau

sal

path

way

O

utp

uts

* Community mobilization for

health & gender rights

Recruitment &

participation * Loan repayment, productive

activities & income

* Health

Seeking

(1)

Improved

environmental

conditions

* Infection

prevention

(5)

* Timely

diagnosis

(2)

* Treatment

completion

(3)

* Sustained

Cure through

MDRTB & (4)

HIV testing

Reduced TB

susceptibility

ISIAT: Conceptual Framework

(a) (b) (d) (e)

D Boccia, J Hargreaves, K Lonnroth, E Jaramillo, J Weiss, M Uplekar, J Porter, C Evans. Cash transfer &microfinance for TB control. IJTLD 2011:15(5);S64-9

2,050 people (329 patients) enrolled to the socioeconomic interventions 12/2007-9/2010

and this interim analysis demonstrates greatest uptake of health promotion activities.

ISIAT– Uptake

100 97 85 50 34 49 97 75 64 22 25 37 96 56 62 14 23 16 0

20

40

60

80

100

(a)Household

visits

(b)Communitymobilization

(c)Psychological

support

(d)Microcredit

(d)Microenterprize

(e)Vocational

training

% o

f p

art

icip

an

ts (

+95%

co

nfi

den

ce i

nte

rval)

Requested Initiated Completed

C Rocha, R Montoya, K Zevallos, A Curatola, W Ynga, J Franco, F Oliver, M Sabaduche, N Becerra, M Tovar, E Ramos, A Tapley, N Allen, D Onifade, C Acosta,

M Maritz, S Schumacher, C Evans. The Innovative socioeconomic interventions against TB (ISIAT) project–an operational assessment. IJTLD 2011: 15(5); S50-57

Excellent uptake

of social

interventions

ISIAT microcredit & TB - Jason Kahn

Of total 151 loans, 36% (55) defaulted.

Associations with default:

• the borrower being male (RR=2.0, p<0.02),

• living in a TB-affected household (RR=1.4, p<0.001),

• and the loan being larger (p<0.001).

Default rates were not associated with:

• schooling completion,

• income / spending, crowding or

• loan multiplicity (all p>0.1).

ISIAT– Uptake

100 97 85 50 34 49 97 75 64 22 25 37 96 56 62 14 23 16 0

20

40

60

80

100

(a)Household

visits


(c)Psychological

support

(d)Microcredit

(d)Microenterprize

(e)Vocational

training

% o

f p

art

icip

an

ts (

+95%

co

nfi

den

ce i

nte

rval)




9% commenced vocational training

3.2% increased income

2,050 people (329 patients) enrolled to the socioeconomic interventions 12/2007-9/2010

and this interim analysis demonstrates greatest uptake of health promotion activities.

ISIAT– Uptake

100 97 85 50 34 49 97 75 64 22 25 37 96 56 62 14 23 16 0

20

40

60

80

100

(a)Household

visits


(c)Psychological

support

(d)Microcredit

(d)Microenterprize

(e)Vocational

training

% o

f p

art

icip

an

ts (

+95%

co

nfi

den

ce i

nte

rval)




Food & cash transfers for all households

$160 average value

=42% of median per capita income

=10% of median household income

23% food – optimized for TB immunity

13% indirect diagnosis & treatment

costs

25% treatment travel expenses

39% supporting microenterprise

ISIAT increased access to TB care



-

10

20

30

40

50

60

70

80

90

100

(1) Health insurance

registration

(2) Contact

screening

(≥18y)

(3) Successful treatment

completion

(4) MDRTB testing

(4) HIV

testing

(5) Preventive

therapy initiation

(<18y)

(5) Preventive

therapy

completion (<18y) Pre-interventions (baseline) After socioeconomic

** ** * ** ** ** **

Socioeconomic interventions were associated with increased uptake of TB control interventions;

follow-up comparing intervention versus no intervention communities is in progress

1. CS Hijos de Grau

2. 20 cases/y

2. CS Pachacútec

26 cases/y

5. CS 3 de Febrero

36 cases/y

15. CS Ventanilla Alta

27 cases/y

14. CS Bahía Blanca

16 cases/y

12. CS Luis Felipe

36 cases/y

11. CS Villa los Reyes

54 cases/y

6. CS Sta Rosa Pachac.

24cases/y

8. CS Cedros

10 cases/y

3. CS Defensores

19 cases/y

16. CS Mi Peru.

80cases/y

10. CB Ventanilla

76 cases/y 4. CS Angamos

37 cases/y

7. CS Ventanilla Este

15 cases/y

13. CS Ventanilla Baja 11

cases/y

9. CS Márquez

42 cases/y

Phased implementation in 8 shantytowns over 3 years to facilitate impact evaluation

Innovative Socioeconomic Interventions Against TB – Project Design

C Rocha, R Montoya, K Zevallos, W Ynga, J Franco, F Fernandez, M Sabaduche, N Becerra, A

Tapley, N Allen, D Onifade, M Tovar, T Valencia, C Evans. Impact of socio-economic

interventions on access to TB care. CDC late-breaker proceedings IUATLD 2010;2.

P<0.0001 P=0.4

P=0.003

P<0.0001 P=0.4

P=0.003

Standard passive programmatic

case finding diagnosed fewer

women (40%) than men.

Our active screening of

household contacts diagnosed

TB slightly more often (51%) in

women than men.

ISIAT – Gender Impact

D Onifade, R Montoya, R Gilman, J Alva, N Becerra, A Gavino, M Rivero, C Evans. Active case

finding overcomes gender barriers to TB diagnosis. IJTLD 2009: 13(12); S150.

Passive case finding under-

diagnosed women; our

active case-finding

overcame this inequality.



Socioeconomic interventions significantly increased the uptake & equity

of TB preventive therapy. A prevalence survey with universal sputum

culture is in progress to determine impact on prevalent TB rates

ISIAT – Equity Impact

25% (114/461)

24% (100/424)

39% (358/921)

39% (401/1029)

0

5

10

15

20

25

30

35

40

45

50

Poverty Marginalisation

Pro

po

rti

on

of

fam

ilie

s

(%

+9

5%

CI)

TB is associated with poverty & marginalisation

Healthy control

families

TB-affected families

P<0.0001 P<0.0001

17% (75/437)

41% (63/154)

28% (121/440)

38% (45/118)

0

5

10

15

20

25

30

35

40

45

50

Control TB-affected families (without intervention)

TB-affected families receiving socio-economic

intervention

Ch

ild

re

n c

om

ple

tin

g c

he

mo

pro

ph

yla

xis

(%

+9

5%

CI)

Socio-economic intervention increases equity of TB care

Poorer

Less poor

P=0.0002 P=0.6

Thanks to:

Presented on behalf of a multi-disciplinary research team in Peru:

Sponsors: World Bank, DFID-CSCF, FIND, Bill & Melinda Gates Foundation,

WHO, The Wellcome Trust, Sir Halley Stewart Trust, NIH, NAMRU-6, IFHAD

Contact: [email protected]

fighting poverty to control tb - who.int · fighting poverty to control tb ... m rivero, cm ford,...

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