Wiping out TB around the world may hinge on India, the WHO reported last week (GHN). Delivering TB diagnostic services and treatment to the country’s hardest-to-reach people is a critical element of the fight, and Project Axshya, supported by the Global Fund and implemented by the Union South East Asia Office, is devoted to the challenge. Axshya (which means free from TB) relies on an extensive network of NGOs and volunteers to reach people across 300 districts in 21 states. Sarabjit S Chadha, a medical doctor and project director with The International Union Against TB and Lung Disease (The Union) in New Delhi, India, heads up the project in the South East Asian region, serves as a member of the regional MDR TB advisory group for the south East Asia region (SEAR), and provides technical assistance to various countries in the SEAR on drug resistance TB. He describes the extent of the TB threat in India and the project’s scope to GHN's Dayna Kerecman Myers for this exclusive Q&A.
Why does India continue to have the highest TB burden country in the world?
India is 17th among the 22 high-burden countries in terms of TB incidence rates. However, due to its large population, this translates into the highest absolute number of TB cases—2.2 million annually. The primary reasons for the high TB burden are delayed diagnosis and treatment which lead to continued transmission. This is attributable to low risk perception and lack of awareness among the general population, coupled with physical and social barriers preventing timely access to quality healthcare especially in rural areas where most Indians live. Simultaneously the country is experiencing rapid economic growth and urbanisation resulting in migration, poor living conditions (slums and homelessness) and inadequate healthcare. In addition, TB remains a highly stigmatized disease and patients avoid getting diagnosed for fear of ostracism and discrimination.
What are the challenges to controlling TB there?
The biggest challenges to controlling TB in India are poor health seeking behavior, weak public health infrastructure and a large unregulated private health sector. This is leading to delayed and inappropriate management of a curable disease resulting in high mortality and drug resistance.
What approaches has Project Axshya adopted to strengthen TB care and control in India?
Project Axshya reaches those with the greatest difficulty in accessing TB diagnosis and treatment through intensified case finding, facilitating diagnosis through sputum collection and transportation, engaging qualified and unqualified healthcare providers, creating awareness about TB in the community (using a mix of mass and mixed media) and most importantly empowering the affected community. Axshya has strengthened community engagement and has created a strong network of over 1,000 local NGOs and nearly 15,000 community volunteers in 300 districts across 21 states. Since 2013, Axshya has reached out to nearly 34 million people from various vulnerable and marginalized communities, facilitated identification and testing of over 700,000 patients with symptoms of TB (including ~550,000 sputum collection and transportation from patients residence) resulting in over 58,000 patients being diagnosed with TB and initiated on DOTS. Axshya has created over 250 District TB forums to address the concerns and challenges of patients in accessing TB services, and has sensitized ~50,000 TB patients on their rights and responsibilities.
Are the results replicable in other high-burden countries?
Yes, the approach adopted in India can be replicated in any high-burden country. The key components include mapping the vulnerable and marginalised communities that are at high risk of suffering from TB, engaging community groups and non-program providers, facilitating identification and diagnosis of those with symptoms of TB and finally ensuring regular and complete treatment of those diagnosed with TB.
The project specializes in getting information on TB to the hardest-to-reach— women, children, tribal populations, communities living in geographically difficult areas, and vulnerable groups, such as people co-infected with TB and HIV. Which of these groups has proven the most challenging to reach—and why?
Axshya has a wide geographical expanse (300 districts across 21 states) with high socio-cultural diversity which poses immense challenges in implementation. Among the vulnerable and marginalized groups, it has been particularly challenging to reach the tribals because of their remote location, strong traditional beliefs and socio-cultural and language barriers. Also it has been difficult to link young children with TB services, due to lack of availability of diagnostic facilities with tests appropriate for children.
WHO seeks to end TB by 2035. Is this goal too ambitious? Is India on-track to meet it?
It is certainly an ambitious goal but not impossible. India has demonstrated its commitment and will to address the challenge of TB—having met the MDGs related to TB—and is moving ahead to ending TB under the SDGs.
What priorities should global TB program managers adopt to end TB by 2035?
There are 3 key priorities for the TB program managers.
First they need to assess the TB situation within their countries and advocate and secure political commitment with adequate resources for TB care and prevention.
Secondly, facilitate integrated patient-centered care and prevention strategies that focus on early detection, treatment and prevention for all TB patients—including children—and ensure equal, unhindered access to affordable services. To ensure this will require multi-sectoral collaboration and addressing social determinants and co-morbidities (diabetes, HIV, etc.)
Thirdly, the program managers need to promote and intensify locally-relevant research and innovations and take steps for rapid adoption and effective scale-up in their countries.
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