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
Intensified Research
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
Pathogens Smear & treat
Care Prevention Innovation
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
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
Intensified Research
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
Pathogens Smear & treat
Care Prevention Innovation
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 µfinance 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
(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
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
(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
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
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
-
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.
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
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]