Population Services International

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Population Services International

• Measurable
• Health
• Impact
• Drives Everything
• We Do

635,000 HIV infections prevented
5.4 million pregnancies averted
45.8 million malaria episodes thwarted
7.4 million diarrhea cases avoided
15.9 million multivitamin pills marketed
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• . . . . AND 10,099 cases of TB patients on DOTS
  treatment to date, generating over 66,995 PYPS.

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Tuberculosis An Ancient Disease
The Heidelberg Man An Egyptian Mummy
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What is Tuberculosis?

• TB is caused by bacteria called Mycobacterium
  tuberculosis
• Spread by coughing and sneezing (air born
  droplets)
• TB is deadly
• However, TB is curable
• Treatment Prevention

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TB Common Symptoms

• Active (pulmonary) TB
• bad cough, lasts 2 weeks
• pain in chest
• coughing up blood or sputum
• skin test (usually)
• may have abnormal chest X-ray, and/or
  sputum smear or culture
• highly contagious each person with active
  sputum smear positive TB estimated to infect 10
  -15 people in a year.

• Latent TB
• usually no symptoms
• do not feel sick
• skin test (usually)
• normal chest X-ray and sputum test
• not contagious
• with normal immune system, only 5-10 of people
  with latent TB will ever get Active TB

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Lungs of a TB Patient
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Even Though Curable, TB Still Kills People Today
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Top 12 Causes of Death Worldwide

• Ischemic Heart Disease (Heart Attacks, Heart
  Failure)
• Cerebrovascular Accidents (Strokes)
• Lower Respiratory Infections (Mostly pneumonia)
• HIV/AIDS
• Chronic Obstructive Pulmonary Disease
• Perinatal Conditions
• Diarrheal Diseases
• TB
• Malaria
• Lung Cancers
• Road Accidents
• Diabetes

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TB A Global Emergency

• has killed over 1 billion people
• kills between 2-3 million people/year (over
  5,000 per day)
• will kill more this year than ever
• 1/3 of the worlds population is infected
• 16 18 million have active TB disease
• 75 of cases currently not tested
• resistance to drugs increasing

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TB A Global Emergency

• 1 global killer of young women (age 15-45)
• gt100,000 children will die from TB this year
• A disease of the poor 95 of those who develop
  active TB 98 of those who die of TB are in the
  developing world

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TB is the leading single infectious cause of
death in South-East Asia
Number of deaths (1000s)
Deaths from infectious agents in South-East Asia
Source WHO 2000
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TB is a Leading Killer of Women
Deaths among women
Source WHO 2000
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TB HIV Cruel Collaboration

• TB is the leading cause of death for
  people with AIDS
• 16.3 million people have both TB HIV
  (co-infection)
• HIV infection results in active TB
• TB may accelerate the clinical course of HIV
  infection
• TB/HIV co-infection concentrated in Africa

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Solution TB Prevention and Treatment DOTS

• DOTS Directly Observed Therapy, Short Course
• 5 components of DOTS
• Detection (sputum smear microscopy)
• standardized, directly observed treatment
  (direct observation for at least 2 months,
  treatment for another 4-6 months)
• reliable supply of high quality drugs
• accountability and a standardized reporting
  system
• political commitment

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TB Prevention and Treatment DOTS

• Detection by sputum smear microscopy
• Standardized, directly observed treatment
  with combination of 4-6 drugs
• Isoniazid
• Rifampicin
• Streptomycin
• Pyrazinimide
• Ethambutol
• Thioacetezone

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Why DOTS?

• Economical - treatment costs only 5-20/person
• Effective - cure rates over 90 possible, even in
  poorest countries
• Helps prevent multiple drug resistance
• Governments who commit to DOTS have access to
  free drugs Global Drug Facility

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TB High-Burden Countries
Top 10
Pakistan Philippines Ethiopia South Africa Russia
India China Indonesia Nigeria Bangladesh
DR Congo Vietnam Kenya Brazil Tanzania
Thailand Mozambique Myanmar UgandaAfghanistan
Zimbabwe Cambodia
Source WHO 2002
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Where in the World Is PSI? TB Overlap!
Pakistan Panama Paraguay Peru Romania Russia Rwand
a South Africa Swaziland Tajikistan Tanzania Thail
and Togo Trinidad Tobago Uganda USA Uzbekistan V
enezuela Zambia Zimbabwe
Eritrea Ethiopia Guatemala Guinea Guyana Haiti Hon
duras India Kazakhstan Kenya Kyrgyzstan Laos Lesot
ho Macedonia Madagascar Malawi Mali Mexico Mozambi
que Myanmar Namibia Nepal Nicaragua Nigeria
Afghanistan Angola Belize Benin Bolivia Bosnia/Her
zegovina Botswana Bulgaria Burkina
Faso Burundi Cambodia Cameroon Central African
Republic China Congo-Brazzaville
(RC) Congo-Kinshasa (DRC) Costa Rica Cote
dIvoire Croatia Cuba Dominican
Republic Ecuador El Salvador
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TB Why PSI? Well, one reason, is that we are
already there

• PSI operates in 17 of the 22 WHO / Stop TB High
  Burden Countries, which account for 80 of the
  worlds TB cases
• PSI has working VCT franchises in African
  countries where HIV/TB co-infection rates are
  high
• PSI has health franchises in Asia where TB rates
  are high and patient seek care in private sector
• TB often concentrated in same high-risk groups
  that PSI already works with daily

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PSI TB Competitive Edge

• motivating healthy behavior change
• tackling highly stigmatized disease
• involving the private sector
• creating incentives for compliance
  (patient provider)
• providing high quality services and information
• logistics expertise and experience

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Roles for PSI in the Fight Against TB

• FRANCHISING
• Integrate TB prevention and treatment into PSI
  social franchises where patients seek care in the
  private sector
• COMMUNICATIONS
• Promote DOTS centers, encourage earlier
  diagnosis, increase compliance, and reduce TBs
  stigma among communities and providers
• VCT Linkages
• Integrate TB screening, referral, and prevention
  into PSI Voluntary Counseling Testing centers
  where HIV/TB co-infection is high Promote
  counseling and testing of TB patients Integrate
  TB into post test services

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Social Franchising to Stop TB

• Myanmar
• incorporating DOTS into Sun Quality Health
  Network and improving health seeking behavior
  (Donors Global Fund, DF, and now DFID)
• supporting World TB Day (Donor WHO/Stop TB)
• Pakistan
• incorporating DOTS into Greenstar network (Donor
  Global Fund)
• outreach and IPC

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PSI TB Treatment and Prevention in the Private
Sector

• PSIs first TB Social Franchising project in
  Myanmar launched in 2004 expected to serve 5,000
  TB patients being treated under DOTS within Sun
  Quality Health franchise
• Targets
• 1,000 TB patients cured by December 2004 (3,000
  more after the end of the project)
• 40,000 new TB infections averted by June 2005
  (based on WHO-endorsed standard multiplier)
• First demonstration of how DOTS might work in PSI
  franchises lessons learned about what will work
  best.

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Encouraging results

• 220 private SQH GPs trained in DOTS in 49
  townships
• More than 7 private labs trained and accredited
• 8,602 cases detected to date 40 new smear
  positive
• SQH now contributes 21 of total new sputum smear
  positive cases in areas where we are active.
• 84 treatment success rate for new smear
  positives (WHO target is 85) 92 for new smear
  negative pulmonary and extra pulmonary cases and
  73 for retreatment cases

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Case detection in the SQH Network
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Impact on Case Detection
Trend of DOTS case notification rates of all new
smear positive cases in SQH townships and control
townships.
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Reaching the Poor
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GreenStar Pakistans Program

• Identify and train private providers
• Recruit and train field staff, including
  treatment supporters
• Develop and market a TB-DOTS treatment package
• Develop a targeted BCC strategy to support the
  social marketing approach
• Implement DOTS through the social franchise and
  referral network
• Conduct monitoring and evaluation of the strategy
  effectiveness

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The CatchChallenges of Implementation

• Requires heavy government involvement
• Complicated technical intervention that requires
  expertise/time
• No quick easy test for TB, no quick easy cure
  compliance is an ongoing issue for all programs
• Doing no harm should apply if you cant do it
  well, dont. MDR TB is a real threat for poorly
  performing programs.

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PSI and TB Communications
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PSI TB The Role for Social Marketing
Communications

• Create demand for highly stigmatized
  service/product
• Reduce stigma of disease
• Increase awareness/knowledge of DOTS testing and
  treatment centers
• Combat sense of hopelessness let community (
  providers!) know cure is possible even if HIV
  positive
• Increase compliance with medications knowledge
  that completion of full regime is key
• Market/promote fixed dose combination drug (PSI
  may use over branded blister packs to increase
  compliance enhance ease of use.)

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PSI Communications Working to Stop TB

• Myanmar with Global Funds PSI DF as part of
  Social Franchising project within Sun Quality
  Health Care network
• Pakistan with Global Funds to support new TB
  project within Greeenstar franchise
• Kenya with CDC funding to support government
  DOTS centers
• Laos Global Fund to support DOTS at government
  sites
• Others to follow Cambodia Nepal? Namibia?
  Nigeria? South Africa?

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World AIDS Day 2003PSI Collaborated with WHO
in Myanmar to Promote DOTS

• Communication Objectives
• Awareness
• Detection
• Treatment
• Reduce Stigma

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Myanmars New TV Mass Media Promotion for DOTS
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Integrating TB VCT ServicesTB HIV Cruel
Collaboration

• TB is the leading cause of death for
  people with AIDS
• 16.3 million people have both TB HIV
• HIV infection leads to active TB
• TB accelerates the clinical course of HIV
  infection
• TB/HIV co-infection concentrated in Africa

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PSI TB and HIV

• TB activities can be incorporated within VCT
  by
• Promoting and providing TB education and training
  wherever HIV services are delivered
• Increasing screening and case finding of active
  TB among HIV positive VCT clients referral of
  active cases to TB DOTS diagnosis and treatment
  sites other HIV positive to IPT programs
• Providing VCT services to TB patients through
  mobile services, training of counselors,
  referrals
• Providing TB preventive therapy (IPT) to persons
  living with HIV/AIDS and co-infected with TB
• Incorporating TB education/services into post-test

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Benefits of TB Screening inVCT Setting

• Provides opportunity to diagnose and treat large
  number of individuals with active TB
• Patients with possibly active infections of TB
  can be segregated from other VCT clients, many of
  whom are HIV
• HIV patients in whom active TB has been excluded
  can benefit from Isoniazid prophylaxis (IPT)
• In process of screening for TB, patients with
  bacterial pneumonia may be diagnosed and treated

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Conclusions

• TB is a major global killer
• TB is curable
• Social marketing has various applications that
  can be tailored to country needs
• PSI has experience, capacity, and on the ground
  presence to effectively join the fight against TB
• For more information please contact Shannon
  England or Dvora Joseph