"Yes! We Will End TB!"
2023 WORLD TUBERCULOSIS DAY COMMEMORATION
Q&A Interview With Prof. Julio RAKOTONIRINA, Director of Health and Humanitarian Affairs, African Union Commission
On this World Tuberculosis Day, the world commemorates World Tuberculosis Day under the theme "Yes! We Can End TB". AIDS Watch Africa (AWA) of the African Union Commission sat with Prof. Julio Rakotonirina, the Director of Health and Humanitarian Affairs at the African Union (AU) Commission to get his view on why it is vital for African Union, its leadership and Member States to reiterate a strong political will to end tuberculosis by 2030.
Why does strong political will matter in the grand scheme of ending tuberculosis (TB) by 2030?
As political leaders brace for emerging threats such as climate change, inflation, food shortages and conflict, priorities shift constantly. We can only be assured that ending a disease will remain a priority when a political actor is willing to commit adequate time, energy, funds and political capital to achieve change, take risks and incur opportunity costs to end the disease.
Additionally, leaders' reaffirmed commitment to end TB influences the country's agenda ownership. Without these two factors, we risk not having enough support to inspire national and collective actions, investments and innovations in fighting preventable disease.
The disease mainly affects the 15-45 age group, which is the active population of the nation. The strong political will to end TB could preserve the backbone of the population and protect the country's economic productivity.
While we reflect on the importance of political will and country ownership, we note that TB is the ninth leading cause of death worldwide, with over 25% of TB-related deaths occurring in Africa. What do you believe are the key factors affecting the TB response in the AU Member States?
One major factor I would point out is the rapid rise of lifestyle diseases such as cancer, diabetes, and cardiovascular diseases are on the rise in Africa. According to the 2022 World Health Organisation (WHO) Non-communicable Disease Progress Monitor, between 50% and 88% of deaths in seven African countries (primarily small island nations) are due to non-communicable diseases (NCDs). Furthermore, the growing burden of non- communicable diseases is projected to exceed communicable, maternal, perinatal and nutritional diseases as the most common causes of death by 2030. Expanding the scope of efforts to address non-communicable diseases will go a long way in improving TB response in the AU Member States.
Secondly, the nature of the disease itself poses a series of challenges. About one-third of the world's population has latent TB, which means people have been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit the disease. When a person develops active TB disease, the symptoms (such as cough, fever, night sweats, or weight loss) may be mild for many months. This can lead to delays in seeking care and results in the transmission of the bacteria to others.
People with active TB can unknowingly infect 10-15 other people through close contact over a year, especially when not seeking treatment. In Africa, 40% of TB cases are under- detected or under-reported, with a critical gap in TB detection among 15 to 44 years old males. The earlier the detection and treatment, the higher the chance of full recovery from the disease. The capacity of the health systems for early detection and treatment should be in coherence with the current demand.
In addition to what I have highlighted, the TB/HIV co-infection continues to be a lethal and aggressive duo. People living with HIV are 20 to 30 times more likely to develop active TB disease than people without HIV. The emergence of multidrug-resistant TB (MDR-TB) poses an added health security threat. Without proper treatment adherence, 45% of HIV- negative people with TB, on average, and nearly all HIV-positive people with TB succumb to the disease.
In conclusion, many more socioeconomic factors contribute to TB prevalence in the AU Member States. Ensuring access to TB prevention, diagnosis, and treatment needs to be key subject matters of discussion this World TB Day and beyond to ensure no more lives are lost to a treatable and curable disease such as TB.
How can AU Member States come together this World TB Day for policy dialogues to ensure that their conversations on addressing the factors driving TB prevalence align with existing policies endorsed by the AU Member States?
As a former Minister of Health, I know for sure that the approach taken by a country to address policies and strategic planning will be contextualised to the national priorities. As we are a continent of many countries and cultures, I encourage looking at the TB-related policies endorsed by the AU Member States to align the conversations at the national level to the TB elimination goals we have set as a continent and globally.
Continentally, the AU Member States align with the TB elimination targets in the Africa Health Strategy (2016-2030) and the Catalytic Framework to end AIDS, TB, and Malaria by 2030. Attention is also paid toward alignment to the AU Agenda 2063: The Africa We Want, Africa's blueprint for achieving inclusive and sustainable socioeconomic development over 50 years. Globally, we all align to refer to the 2030 Agenda for Sustainable Development (SDG 2030) and Global End TB Strategy (2023-2030).
The existing continental policy frameworks primarily emphasise three strategic areas: integrated patient-centred care and prevention; bold policies and supportive systems; and intensified research and innovation. They also champion decentralisation and strategic integration of HIV and TB services to bridge the case detection and treatment gaps. The policy dialogue should consider all the existing TB-related policies, the strategic objective these policies highlight, and the country's context. Good policies only work when applied to effective and functional health systems.
Beyond this, the AU Commission is in the process of completing a continental Digital Health Strategy. This initiative integrated into the ongoing operationalisation of the AU Free Movement Protocol needs to be considered in the TB response conversation. Opportunities for cross-country TB care can be discussed among AU Member States and adopted across the continent as a joint effort to manage the disease using digital innovations.
Beyond aligning to strategies recommended in existing policy frameworks, are documented good practices available for adoption to reduce the TB new infections and prevalence in the AU Member States?
Each time the list of 30 high TB-burden countries is released, some AU Member States transition out while others join. In the last list produced in 2020, the Republic of Zimbabwe transitioned out, while Gabon and Uganda joined the list. This cycle shows that some good practices are being implemented and existing challenges that all need to be discussed among the AU Member States for collaborative action against TB.
In Zimbabwe, for example, the Ministry of Health and Child Care adopted Community ART Refill Groups (CARGs) as a delivery model of tuberculosis preventive treatment (TPT) for people living with HIV (PLHIV). It is an opt-in, peer-led, community-based group treatment model. It includes 6-12 people who meet quarterly in the community to distribute ART, monitor adherence, screen for symptoms of illness, including TB, and provide mutual support. Each CARG has a peer leader, who is also on ART, coordinates meetings, documents activities, and communicates with health facility (HF) staff. Similarly, Ethiopia and Senegal have boosted TB detection using health extension workers (HEWs).
In Zambia, an integrated TPT was adopted into that country's Fast Track treatment model, providing multi-month dispensing of both antiretroviral therapy (ART) and TPT to adult PLHIV established on treatment at health facilities. Preliminary results suggest that this may have increased the uptake of TPT among the target group.
Senegal, Benin, and Guinea Conakry are also implementing the RafaScreen Project to screen TB in PLHIV and diabetics to integrate TB and NCD care. Closely related, Niger and Cameroon adopted a comprehensive care package for MDR-TB patients.
The possibilities for TB services decentralisation and community engagement from the Ministry to the household level are endless. It is necessary for the AU Member States to be sensitive to their national TB program teams to capitalise on findings collated by academia and research institutions on TB.
Are there potent opportunities that other countries can leverage to reduce prevalence?
Using the example of Uganda, the Ministry of Health issued a directive in 2016 for integrating childhood TB into maternal and child health (MCH), HIV and nutrition services into MCH clinics. In partnership with development organisations, the Ministry trained 400 midwives at 230 supported health facilities to integrate TB diagnosis and management into eliminating mother-to-child transmission (EMTCT) services. However, expanding the health workforce to include community health workers (CHWs) requires national commitment and investment to ensure efficiency and sustainability.
Domestic investment in health systems is also an opportunity and a necessary complement to TB control programs. There are many ways of mobilising domestic resources to strengthen health promotion, improve diagnostic capabilities and provide preventive therapy to young children and other family members. Governments of AU Member States endorsed the 2019 "Addis Ababa Commitment towards Shared Responsibility and Global Solidarity for Increased Health Financing Declaration" (AU Assembly ALM Declaration) , which recalls the 2001 Abuja Declaration and reiterates a call for African-led domestic resource investment into the health sector.
This demonstrates the added value of working with community health workers (CHWs) to provide job aids and tools to monitor the integration of the TB programme into the broader health services. They could provide technical support for midwives to provide TB services according to national guidelines.
How can AU, its special organs and its partners play a central role in addressing the challenges mentioned and strengthening the TB response in AU Member States?
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As I mentioned earlier, community health workers are an excellent opportunity to fight against TB. However, strengthening community systems and promoting multistakeholder leadership in the TB response can only succeed through cross-nation and cross-sectoral partnerships. The convening power of the African Union, coupled with the availability of funding from the development partners, can be leveraged to transform and document TB response in all 55 AU Member States.
Beyond documentation, stakeholders can support the AU Member to convene regularly to discuss the barriers and the challenges, as well as the opportunities and enablers; the planning and implementation steps taken, including the stakeholders involved; the tools used to monitor and evaluate the intervention; the results, even if preliminary; and the lessons learned and relevance and applicability of the intervention to other contexts.
Overall, the AU, its Member States, Special Organs and partners can collaborate to collate knowledge about innovative approaches (for example, tools developed to screen patients for TB; integrated and decentralised models of care; progressive scale-up of MDR-TB care using short regimens and new knowledge developed by researchers). The evidence collected can be used to identify and apply tailor-made and context-specific solutions. Furthermore, the positive results can increase scale-up, replication, and advocacy momentum.
What is your call to action to AU Member States this World TB Day?
I believe that "Yes! We Will End TB!"
In my perspective, the theme "Yes! We Can End TB" unites all of us in a spirit of hope to end TB by 2030. It is a reminder of the few years left to meet the TB elimination goals. The vision for AU Agenda 2063: The Africa We Want is an African-led transformation. We should strive as a continent to honour our commitments and re-energise our efforts to tackle the economic, social, cultural, and legal inequalities that drive TB.
There should be a healthy exchange between AU Member States regarding their approach to TB response so that success stories are being shared for assimilation and the challenges are addressed jointly. I have done my part as a leader and medical practitioner in the TB field to document my experience and published my findings titled: "Contextual Approach to Tuberculosis Control: The Case of Madagascar". TB is airborne and thus a cause of concern for all. We have to make progress together as a community, leaving no one behind.
As a passionate advocate for TB, I will continue to use my voice to champion TB elimination in Africa. Join the movement this World TB Day.
