The journey to ending tuberculosis (TB) has taken a significant leap forward with projects like the Unitaid funded IMPAACT4TB project, which aims to scale up the implementation of shorter TB preventive treatment (TPT) regimens. As part of this initiative, sharing experiences from pioneering countries is invaluable for understanding the practical challenges and successes in rolling out these treatments. When implementing shorter TPT regimens, the experience of Indonesia, Ethiopia and Tanzania, as pioneers in this strategy, serve as a vital learning opportunity for expanding TPT uptake globally.
Aligned to this and aiming to make this available to a larger audience, we prepared and conducted a webinar supported by representatives of countries Dr. Yeremia Runtu (Indonesia), Mr. Taye Letta (Ethiopia), and Dr. Peter Neema (Tanzania); Dr. Jerod Scholten, Dr. Christiaan Mulder and Dr. Vijayashree Yellappa, from KNCV Global Office; and Ms. Makaita Gombe, from the Aurum Institute in South Africa.
About the webinar “Pioneering Pathways: Implementing shorter TB Preventive Treatment, Populations at risk and more”
The webinar was comoderated by Dr. Scholten and Ms. Gombe, who reflected and guided the session on lessons learned from the IMPAACT4TB Project. They highlighted that early adopters not only provide key insights to overcome barriers but also helped other countries to refine their approaches.
Ms. Makaita Gombe, Project Director for IMPAACT4TB from the Aurum Institute in South Africa, provided a comprehensive update on the IMPAACT4TB project. Initially, Ms. Gombe started reflecting on TPT uptake being at around 49% in 2019, despite World Health Organization (WHO)‘s guidelines for short-course TPT regimens (2018). The IMPAACT4TB project’s enabling factors launching shorter TPT regimens such as 3HP (3 months of weekly doses of rifapentine and isoniazid), has resulted in significant progress. The project addressed early concerns about 3HP use, particularly among people living with HIV (PLHIV) and children.
Several clinical trials (such as the DOLPHIN and TBTC studies) confirmed the safety and efficacy of 3HP, this led to the successful roll-out of shorter TPT regimens in 12 countries. To date, key achievements include:
- significant price reduction of 3HP,
- increased supplier capacity of rifapentine;
- wider global uptake of 3HP, with over 10 million patient courses procured across 99 countries;
- development and roll out of additional shorter TPT options such as 1HP (28 daily doses of rifapentine and isoniazid);
- and new child-friendly (fruit flavored and dissolvable in water) formulations of shorter TPT regimens.
Challenges and lessons learned from shorter TPT regimens implementing countries: Indonesia, Ethiopia and Tanzania
For this webinar we invited Dr. Yeremia Runtu, Associate Director of Yayasan KNCV Indonesia, Mr. Taye Letta, Program Manager at the National Tuberculosis, Leprosy and other Lung Diseases Program in Ethiopia, and Dr. Peter Neema, Program Coordinator of the National Tuberculosis Program in Tanzania, who have been deeply involved in the implementation and roll out of shorter TPT regimens in their contexts. Reflecting on their experiences, the country representatives shared similar challenges and lessons during their efforts to scale up shorter TPT regimens:
- Supply chain and logistics: Issues such as drug stock outs, insufficient diagnostic tools (TB infection testing and X-rays capacity), and delayed supply chains were observed to be common across Indonesia, Ethiopia, and Tanzania. Stock outs experienced by countries was related to local supply chains and financial reasons. This affected the consistent availability of 3HP and diagnostic tools for TB infection. Shortages experienced at global scale in early stages of the project have been resolved now. Strengthening supply chains is crucial and there is a pressing need for reliable logistics to ensure consistent availability of 3HP and other short TPT regimens and diagnostic tools for TB infection.
“…there is the need for waiver for importation of rifapentine ant the need to include it in the Essential Medicine List (EML) is time taking, that is the challenge… there is another need to include in the Integrated Pharmaceutical and Logistic System (IPLS).”
– Mr. Taye Letta, Program Manager at the National Tuberculosis, Leprosy and other Lung Diseases Program in Ethiopia
- Community engagement and awareness: The speakers of the three countries reported low awareness about the benefits of TPT, both among healthcare workers and communities. Misconceptions and poor perceived risk of TB infection led to low acceptance and uptake of TPT. It is essential for improving acceptance and adherence to treatment that we develop strategies to building trust and knowledge in communities.
“…but most important, there’s still lack of awareness of TPT advantages among the community.”
– Dr. Yeremia Runtu, Associate Director of Yayasan KNCV Indonesia.
- Capacity building: Limited training and capacity among healthcare workers was a significant challenge. Indonesia, for example, faced issues in healthcare workers’ understanding of TPT guidelines, while in Tanzania gaps were reported on adverse event monitoring and healthcare worker capacity. Continuous training, particularly around new guidelines (recently published update on the WHO Guidelines on TPT) and regimens, is needed to ensure smooth implementation of shorter TPT regimens and programmatic delivery.
- Policy and funding gaps: Mr. Letta from Ethiopia and Dr. Runtu from Indonesia, highlighted the lack of clear national policies to support TPT, particularly regarding coverage by national health insurance and involvement of private sectors. The lack of involvement from the private healthcare sector in TPT provision may restrict the program’s reach. Clear policies and partnerships with private providers can greatly enhance TPT access and success.
“…event monitoring is supposed to be conducted when the country starts adopting new regimens. We have already developed these protocols but we are faced with a funding challenge for its implementation.”
– Dr. Peter Neema, Program Coordinator at the National Tuberculosis Program in Tanzania
Ongoing research on implementing shorter TPT regimens
Dr. Christiaan Mulder, Senior Epidemiologist at KNCV Global Office, presented updates and current status of research conducted within the project. He commented that research efforts, such as the CAT and CHIP-TB cluster randomized trials, have been crucial in studying access to TPT service delivery, particularly among PLHIV and children. Studies like CHIP-TB also tested home-based TPT delivery and found it reduced costs for households while improving uptake and being much more family-centered than facility-based care. Additionally, Dr. Mulder mentioned implementation strategies for sustainable and resilient home-based TPT services.
Private sector engagement
In terms of private sector engagement, we had Dr. Vijayashree Yellappa, Senior TB Consultant at KNCV Global Office, with extensive experience in TB and Public-Private Mix reflecting on the involvement of private healthcare sector in TB care and TPT provision. She reflected that the country speakers highlighted private sector engagement for TPT remains limited across the countries. Dr. Yellappa emphasized the critical role of private sector engagement in expanding access to TPT. She highlighted barriers such as skepticism and lack of awareness among private providers. She stressed how effective public-private partnerships can improve TB prevention and care. Public-private partnerships can ensure stronger and more consistent TB preventive treatment provision in the private sector where many clients prefer to receive their medical services. Finally, she concluded that partnerships between the public and private sectors are essential to improve TPT provision and access.
Concluding remarks
In conclusion, the experiences shared by Dr. Runtu, Mr. Letta and Dr. Neema, together with the technical expertise from Ms. Gombe, Dr. Mulder and Dr. Yellappa highlighted the progress made in implementing shorter TPT regimens. They also acknowledged several ongoing challenges.
“…despite the challenges, there’s been significant progress to adopt 3HP as one of the options for TPT among the household contacts, PLHIV and other risk groups…”
– Dr. Yeremia Runtu, Associate Director of Yayasan KNCV Indonesia.
Key recommendations included:
- strengthening supply chain management;
- increasing community awareness;
- expanding healthcare worker training;
- and strengthening policies and frameworks to foster private sector collaboration in TB care and TPT provision.
The IMPAACT4TB project has made significant strides. However, achieving global TB elimination goals will require sustained collective efforts. These collective efforts include significantly expanding TPT coverage to populations at high-risk and ensuring that TPT is accessible in both public and private sectors.
Watch the recording HERE, and download the PPT Slides HERE.
The IMPAACT4TB Consortium is funded by Unitaid and is a partnership among The Aurum Institute, KNCV Tuberculosis Foundation, Clinton Health Access Initiative (CHAI), Johns Hopkins University, Treatment Action Group (TAG) and the Stop TB Partnership’s Global Drug Facility. Learn more about the consortium HERE.