Looking back at five successful years of Challenge TB

The KNCV-led, USAID-funded Challenge TB (CTB) project operated from 2014 to 2019 in 24 countries and two regions. The overall purpose of CTB was supporting countries with high burdens of tuberculosis (TB), multidrug-resistant TB (MDR-TB), and TB/HIV to achieve their National Strategic Plan goals, contribute to the US Government TB Strategic Targets (2015 -2019) and strive toward the post-2015 global goals. 10.2 million people were successfully treated for TB and 275.000 patients put on treatment for DR-TB.

CTB was the fourth in a series of flagship projects and built on previous projects’ experience and gains. The project had a ceiling budget of US$ 524,754,500.

Four core principles guided the work of CTB:

1. A patient-centered approach
2. Local ownership through the transfer of knowledge and skills
3. A culture of innovation
4. A continuous emphasis on quality.

Four strategies complemented these principles and led to:

• Engaging all stakeholders through a comprehensive, multi-sectoral approach.
• Empowering decision-makers, national TB programs (NTPs), and other local partners by
building their leadership management, and technical capacity.
• Evaluating interventions and innovative approaches, measuring their results, and
using evidence to develop targeted, high-yield solutions.
• Expanding access to the full range of providers and removing barriers to services.

Coordination, collaboration, and complementarity with TB stakeholders at all levels drove the success of CTB and improvements in global and national performance in TB. For sustainability, everything was done through national health systems and with local partners, as part of countries’ journey to self-reliance. Capacity building of NTPs, local organizations, and health care workers prepared these partners to identify gaps, develop work plans, and implement and monitor interventions.

From 2014 to 2019, the project signed 387 sub-awards in various technical areas of TB prevention and care with 163 organizations, of which 152 were local organizations. Also, CTB supported training of 175,915 health care workers in areas related to diagnostics, TB care and treatment, and management of TB programs, including monitoring and evaluation.

High quality case finding and care

CTB contributed significantly to increased access to high-quality case finding and care
for both drug-sensitive and drug-resistant TB (DR-TB) through different complementary
initiatives. Of all case finding interventions, the yield is highest to lowest in the following order: strengthening health care facility/outpatient department TB screening, community referral, and the private sector. Contact investigation was useful to increase case finding but most importantly, it served as an entry point for latent TB infection (LTBI).

The number of TB cases diagnosed and initiated on treatment increased, from 51% national treatment coverage for all 24 CTB countries combined in 2014 to 67% in 2018. The overall treatment success rate was 85%, with 10 countries exceeding 90%. Similarly, the number of DR-TB cases diagnosed and enrolled in care increased to 42% and 89% from the baseline in 2014, and 17 CTB-supported countries achieved DR-TB treatment success rates of 60-80% compared to a baseline of 55%, exceeding the global average of 56% because of rapid decentralization of care to the community level, strengthen active TB drug-safety monitoring and management (aDSM), and improved data quality.

Between 2014 and 2018, the number of countries putting more than 90% of TB/HIV
patients on antiretroviral treatment increased from two to eight. In 2018, more than 90%
of TB patients were tested for HIV in seven countries (two of those reported 100% testing
coverage). There is still a gap on LTBI enrollment and reporting by countries; less than 50% of countries have quality data on isoniazid preventive treatment (IPT) including reporting to WHO. However, the number of people living with HIV (PLHIV) both newly enrolled and currently enrolled in HIV care who started treatment for LTBI increased from 343,363 in 2014 to 729,640 in 2018 in the 15 countries reporting data.

Increase in access to quality diagnosis

Access to quality diagnosis increased due to the systematic introduction of laboratory strengthening and optimization initiatives. The number of laboratories performing culture and drug susceptibility testing almost doubled, from 118 in 2014 to 213 laboratories
by 2019. The percentage of laboratories implementing a laboratory quality management
system also increased, from 50 laboratories to 126 laboratories.

The dramatic expansion in the use of GeneXpert – 4,561 GeneXpert machines were available in 24 countries in 2019 compared to 990 in 18 countries in 2015 – enabled the scale-up of testing for multidrug-resistant TB (MDR-TB), which increased from 7% in 2014 to 87% in 2018 among all newly diagnosed bacteriologically confirmed cases. Access to second line probe assay (SL-LPA) improved from 47% in 2015 to 63% in 2018 among all DR-TB cases.

The shorter treatment regimen (STR) and new drugs and regimens (ND&R) were
systematically introduced in 23 countries ( except for South Sudan), with a standard approach for the future introduction of new medicines and tools.

There were promising interim outcomes among 779 patients treated with bedaquiline: 71% had negative results at the end of six months. The WHIP3 trial study found that 3HP was safer and had better adherence and treatment outcomes (90% among 3HP compared to 50.5% among patients on isoniazid). The study also demonstrated that there is no need for repeated 3HP among PLHIV.

Focus on strengthening systems

Systems strengthening was a major focus and included helping local staff to use data
to drive the selection, targeting, and performance improvement of interventions. Phased
implementation of packages of interventions proved more effective than isolated or
small scale interventions, for scalability and sustainability.

The introduction and decentralization of innovations such as new drugs and regimens required flexibility, advocacy, and problem-solving. CTB helped countries to create processes and platforms for locally-owned research and effective change management. These platforms accelerated the introduction and uptake of innovations, enabling countries to manage not only the changes of the present era but also those of the future.

Important scientific contributions

CTB made important contributions to the science of TB. In total, 35 operations research studies were completed and a total of 213 manuscripts were developed and shared through various channels. Three projects with core funding developed tools for stigma measurement and implementation; assessment of catastrophic costs to patients; and the efficacy of different combinations of drugs to prevent TB infection in PLHIV.

LESSONS AND RECOMMENDATIONS

• Engagement of NTPs in the entire project cycle enabled implementation at scale and promoted sustainability.
• The use of a package of interventions customized to each country’s needs guided implementation and is a best practice.
• As a functional laboratory network is key to a successful TB program continued investment in laboratory strengthening is recommended.
• A two-part approach to advocacy at the national level was effective: with politicians
and policymakers for domestic funding, and with professional and regulatory bodies for
the uptake of innovations, new tools, and new medicines.
• Coordination, collaboration, and communication among all TB stakeholders were crucial
for project efficiency and success.

Mustapha Gidado, KNCV Interim Executive Director:

“All these lessons, best practices, and TB platforms are also applicable for the COVID-19 pandemic response but we should all guard ourselves against possibly losing the gains we made in the last five years.”