There is clear urgency for bringing quality and effective tuberculosis (TB) prevention, treatment and care closer to communities. These efforts should entail empowering communities to use innovative community-based TB services, which have been shown to have a high impact and to be cost-effective.
There has been an unprecedented global mobilization to support countries to end the TB epidemic. These efforts saw the scaling up of TB treatment for an additional 7 million people in 2018 and a reduction in TB-related deaths among people living with HIV by 52% since 2010.
Significant progress has been made towards reaching the United Nations High-Level Meeting on Tuberculosis target of 6 million people living with HIV accessing TB prevention services by 2022—1.8 million people living with HIV started TB preventive treatment (TPT), which reduces their risk of developing active TB disease, in 2018.
However, there are major issues of concern. During 2018, a total of 1.5 million lives were lost to TB, including 251 000 among people living with HIV, which is a third of that year’s 770 000 AIDS-related deaths. Around 10 million people fell ill with TB, 9% of whom were coinfected with HIV. We are still far away from reaching the global target of reducing TB deaths among people living with HIV by 75% by the end of 2020. While the estimated number of new TB cases among people living with HIV in 2018 was 862 000, only 56% of them were aware of their TB status. Less than half of the people living with HIV who newly initiated antiretroviral therapy in 2018 reported also initiating TPT.
More people-centred and community-based approaches that bring services closer to people in need are real game-changers and need be scaled up. For example, as an alternative to the six-month daily TB treatment regimen requiring patients to visit a clinic daily and be monitored by health-care workers that is implemented in some countries—the so-called directly observed therapy (DOT) approach—many programmes are experimenting with digital adherence technologies.
The medication event monitoring box approach involves the patient’s medicines being in a box—a signal is sent to the clinic each time the patient opens the box to access his or her TB medicines. The video DOT method involves patients recording themselves and sending a daily medication update video to their clinic.
These technologies are user-friendly and reduce the time that people are away from their regular activities and reduce the cost of daily transport to the clinic. They provide people with autonomy and empower them to manage their treatment and their health in their home while being monitored for treatment adherence, as well as improving access by vulnerable groups and reducing stigma.
The LF-LAM (lateral flow urine TB mycobacterial lipoarabinomannan) is a simple rapid point of care urine test that the World Health Organization recommends as a game-changer and as a part of a diagnostic algorithm for people living with HIV. It allows the testing of adults and children in health facilities and community-based settings. To date, however, only seven countries among 30 high-burden countries are implementing the LF-LAM tests.
Newer shorter regimens for TPT, such as three months of weekly rifapentine and isoniazid, have been increasingly available owing to recent price reductions and policy shifts. The regimens have fewer side-effects than longer regimens and higher rates of completion. Communities play a key role in supporting people living with HIV to initiate and complete TB preventive treatment, monitor side-effects and seek care for early signs or symptoms of TB.
“Especially in this time of COVID-19, we absolutely need to move on innovative models that allow people to continue their care at home. This means putting in place the quality and supports that people can access virtually, by telephone and in the community. It means delivery models that recognize and respond to the daily constraints on people’s lives and putting the tool directly in their hands to succeed. Let’s empower people to stay connected, continue their care and access additional supports including facilities when they matter most,” said Shannon Hader, the Deputy Executive Director, Programme, of UNAIDS.