Union collaboration with Belarus, South Africa and Viet Nam shares experiences and push for rapid policy change, to highlight the challenges and opportunities of translating international TB treatment guidelines into national strategic plans.

An article recently published in PLOS discusses how tuberculosis (TB) treatment guidelines are translated into national strategic plans, by referring to the experiences of three different countries. The article Advances in clinical trial design for development of new TB treatments—Translating international TB treatment guidelines into national strategic plans: Experiences from Belarus, South Africa, and Viet Nam was led by Dr Grania Brigden, The Union’s Director of the Department of Tuberculosis.   

In the article, the case studies from the national TB programmes (NTPs) of three high-burden countries describe national experiences in the implementation of recent World Health Organization (WHO) guidelines on bedaquiline and the standardised shorter treatment regimens for multidrug-resistant TB (MDR-TB). The case studies illustrate how different countries approach the implementation of new policies and drugs for TB treatment and highlight some of the generalised challenges that NTPs in high-burden countries have experienced. For example, the analysis highlights how the process of adopting and scaling up bedaquiline, is a complex process, involving multiple agencies, and is prone to delays from ethical, surveillance, and regulatory processes, and often requires the undertaking of pilot projects prior to national implementation.

The comparison of the different settings suggest that intergovernmental collaboration and new guideline adoption and implementation are facilitated when TB has been placed high on the political agenda. Belarus, South Africa, and Viet Nam have benefitted from high levels of political commitment to TB and have been some of the first countries to scale up the use of new drugs and the standardised short course regimen.

Another factor affecting successful implementation and scale-up of WHO guidance is the availability of pathways and tools developed by NTPs to implement new TB drugs and regimens for MDR-TB. With strengthened programmes, NTPs can generate the evidence to show whether what is found to be effective in clinical trials will work amongst the populations that need them most and feed this back to WHO to contribute and strengthen future guidelines.

Recently, the rate of new advances in TB diagnosis, treatment, care, support and prevention has been increasing, with the accompanying increase in WHO guideline revisions, and this pace of development will continue. NTP’s play a key role in regularly updating national policies or technical guidelines and ensuring these advances will have an important impact on the quality of care for people with TB.

However, such rapid change, in conjunction with other barriers to the adoption of international treatment guidelines, has meant that a number of these new treatment policies have not been adopted or fully implemented by national programmes.

The authors point out that the high numbers of TB drugs and regimens in the pipeline will require NTPs to adapt by adopting a culture of change. Countries must support their NTPs in this process. In addition, all stakeholders must support this approach to change, including international donors, national funding and regulatory agencies, with funding and policy support being available so that NTPs can successfully review and adopt the best standard of care for people with TB.

Dr. Norbert Ndjeka, Director of Drug-Resistant TB, TB & HIV from South Africa’s Department of Health said: “I urge NTPs to implement WHO DR-TB policy and strongly consider operational research projects that will support their own programmatic decision-making processes and contribute to global knowledge on drug-resistant TB. We still have a lot of unanswered questions.”

The issue of "country readiness", relating to the efficiency with which governments are prepared to integrate new tools that come out of the TB R&D pipeline was touched upon recently by Paul Jenson in his report: Reflections from the UN General Assembly and High-Level Meeting on Universal Health Coverage. He says: “If countries are going to make the most use of shortened treatment regimens, better diagnostics or even a new vaccine, it's critical to do the prep work in advance.”

Last week, the launch of The Global TB Report 2019 highlighted that in 2018:

  • 484,000 people fell ill with TB that was rifampicin-resistant (RR-TB), and of these, 78 percent had MDR-TB.
  • 187,000 cases of MDR/RR-TB were detected and notified in 2018. Of these, a total of 156,000 were enrolled and started on treatment with a second-line regimen.
  • The treatment success rate for MDR/RR-TB is 56 percent.