Global Fund grant to Ukraine finds treatment success for multidrug-resistant TB with two-pronged approach

Author: Ivan Varentsov, EHRA Sustainability and Transition Advisor and Coordinator of the EECA Regional Platform for Communication and Coordination

According to the WHO, Ukraine remains a country with a high TB burden, and in 2014 it became one of the five countries with the highest burdens of multidrug-resistant tuberculosis (MDR TB) in the world. The TB epidemic in Ukraine is marked by the spread of multidrug-resistant and extensively drug-resistant tuberculosis (XDR TB), relatively high MDR TB mortality and one of the lowest TB treatment success rates in the region of Eastern Europe and Central Asia – 72% in new TB cases and 38,6% in patients with MDR TB (WHO, 2016).

Currently the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) is supporting the implementation of programs to fight tuberculosis in Ukraine within a new country HIV/TB grant for 2018-2020, as well as through catalytic funding. The current program, which started this year, is being based on the previous three-year project, “Investing for Impact against Tuberculosis and HIV”, which had been implemented in Ukraine in 2015-2017 and was completed, with success, at the end of last year.

One of the three key implementers of this project was the Alliance for Public Health (the Alliance), which was responsible for a number of program components, in particular for providing medical and social support to ensure adherence to MDR-TB treatment. Implementation of this latter component achieved high success rates (up to 80%).

Key success factors and outcomes

One of the key factors contributing to the success of this project component was the use of the DOTS approach (Directly Observed Treatment Short-course) in combination with social support for patients, which included the delivery of psychosocial services and training in treatment adherence. This project was implemented in all regions of the Ukraine and performed strongly in all of them.

Apart from the Alliance, other partners involved in implementation included the Public Health Center of the Ministry of Health of Ukraine and the Ukrainian Red Cross Society. The Red Cross Society, which has a wide network of branches covering all the regions of Ukraine, and also has the required number of visiting nurses, was responsible for the DOTS and social support components of the project.

Before patients were released from hospitals, they were asked if they would like to be involved in the project at the outpatient stage of treatment. If the person agreed, information about the patient was given to a relevant branch of the Red Cross Society, where a supervisor was assigned to receive that patient’s TB drugs, attending to the patient daily. If the patient did not miss any doses, he would receive food parcels twice a month.

The efforts of the Alliance and its partners to provide medical and social support to patients and establish their adherence to MDR TB treatment within this project continued the work that had been started in 2013 with the implementation of the previous Global Fund TB grant from Round 9. In 2013, just over 100 patients were enrolled in the support program. Treatment success rates were very high, at 86%, while the treatment success rate for patients with similar conditions who also received treatment within the Global Fund project but were not covered with DOTS or by social support from the Red Cross, was 44% (according to the Alliance).

According to one staff member from the Alliance, one of the reasons for such high treatment success rates was the approach the program used to select patients: at first patients for whom good treatment outcomes were expected were enrolled in the program – ‘treatment-naïve’ patients, patients with repeated TB cases (if the previous TB case was cured) and patients whose first treatment courses had failed. Further, starting from 2014, all patients eligible for the treatment regimens procured within the Global Fund project were enrolled in treatment. After 2015, the patients who received treatment within the state budget were also enrolled in the program.

In 2014, the treatment success rate for the 500 patients covered by the project was 79%, and in 2015 it was 75%. The target for patient coverage in the three years from 2015 to 2017 was 9,300 patients, and was overachieved – the actual number of patients with MDR TB covered by the program was 9,420. (Treatment success rates for the patients enrolled in 2016 will be available later in 2018.

According to Eugenia Geliukh, the program’s project manager, the program can be credited with improving the overall MDR-TB treatment success rates in the country: In 2012 it was 34%, in 2013 it was 39%, and in 2014, 46% (WHO Tuberculosis country profile).

Ensuring sustainability of the TB response in Ukraine

“In three years, we fully piloted the DOTS model combined with social support of the patients and proved the efficiency of this project in Ukraine,” says Andrey Klepikov, Executive Director of the Alliance for Public Health. “Our main message to the government is to make sure that, considering the existing evidence base and taking into account the ongoing processes of transition of TB programs from Global Fund support to domestic funding, this component will also be taken over by the state.” Klepikov suggested that treatment success rates would be halved if, after the withdrawal of Global Fund support, the government supported only drug procurement, without the social support component.

This aspect is crucial as in recent years there has been a rapid transition of the TB response to domestic funding. Until 2017, procurement of half of the second-line drugs to treat multidrug-resistant forms of TB in the country was covered by the Global Fund; starting in 2018, the government took over the procurement of all TB and MDR-TB drugs. Moreover, it is planned that by the end of 2018, 90% of XDR-TB treatment will be covered by domestic funds. The remaining 10% will be procured by the Alliance within Global Fund programming (133 schemes with delamanid).

So far, the equipment for rapid TB diagnostics, supplies and reagents are mainly procured with financial support from the Global Fund and other donors. According to the new Global Fund grant agreement, to implement the 2018-2020 HIV/TB project, every year the procurement of equipment will incrementally be covered from the state budget. Currently, a National TB Program concept has been approved in Ukraine, and it is expected that this year the Parliament will approve the National TB Program for 2018–2021.

Within the new grant, in 2018, support for patients who receive treatment will remain the responsibility of Alliance, in eight regions of the country, with no Red Cross Society involvement. However, it is planned that the social component will also gradually be taken over by the government. In 2018, it is projected that social support for 20% of patients receiving support from NGOs will shift to the Ministry of Ukraine’s Public Health Center. Financial support for this activity will still come from the Global Fund, and the Alliance provides technical support to the PHC within this component.  Starting from 2019, 50% of patients will receive support from within the state budget and in 2020, it is expected that 80% of the patients will receive support from the state.

TB treatment approach based on results-based financing model

The Alliance also has implemented a pilot MDR-TB treatment project using a results-based financing (RBF) model. In 2017, the Alliance applied this approach when implementing opioid substitution treatment programs in the Odessa region, within the same Global Fund grant, and decided to adapt it to TB treatment based on the DOTS model. The main goal of the project was to reduce treatment costs per patient per year, and to hand over the implementation of DOTS and social support for TB patients to the primary-care level of the state healthcare system.

“Involvement of the Red Cross Society or other NGOs in DOTS implementation is an interim solution,” says Eugenia Geliukh. “Such projects can be implemented only as long as donors support them. As soon as donors stop financing those activities, NGOs will not be able to continue them at their own expense. At the same time, delivery of treatment services through primary healthcare centres (PHCCs) is in line with the concept of the healthcare reform which is currently going on in Ukraine.”

Within the project, Alliance signed contracts with 14 PHCCs in the Odessa region to implement DOTS and provide social support to patients receiving treatment. The specific mode of providing DOTS services was defined by each PHCC.

Within the pilot project using the RBF model the cost of treating one MDR TB patient for one year was UAH 9,000 (compared to UAH 13,000 for the Alliance project) with the same outcomes. Treatment success rates for the MDR TB patients are not yet available as they have not yet completed their treatment. But for the patients with drug-susceptible TB, the average treatment success rate was 93%, compared to the 35–40% registered in some Odessa region districts before the pilot project implementation started.

This project was not included in the new program supported by the Global Fund for 2018–2020. Moreover, within the new programme the government made a decision to go back to DOTS provision by NGOs and not by state-run primary healthcare institutions. But the city of Odessa became interested in the pilot project’s results. The annual budget of UAH 2,2 million (which is equivalent to $85,000) is allocated within the Odessa city HIV/TB program for 2019–2020, to cover up to 700 people with DOTS through primary healthcare centres. In 2019 half of these funds are expected to be covered by the city budget, and in 2020, 100%.

“In the end, the results-based financing model has been accepted and supported with municipal funding,” said Andrey Klepikov, executive director of the Alliance for Public Health. “It is a great victory for ensuring sustainability and transition. And civil society will remain one of the key players in our national TB response, becoming more and more recognized by the Ukrainian government.”

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Announcement of EHRA members online Regional and General meetings to elect Steering Committee members

Dear EHRA members,

Eurasian Harm Reduction Association (EHRA) (Eurazijos žalos mažinimo asociacija), registered at Gedimino pr. 45-4, Vilnius 01109, Lithuania (actual address Verkių g. 34B-701, Vilnius) announces the convocation of the members regional meetings from the particular regions: Central Europe, Ukraine-Moldova-Belarus, Caucasus, Central Asia and community of people who use drugs.

Please, find a list of all current Steering Committee members.

A list of Steering Committee members subject to rotation in the Regional meetings:

  1. Iveta Chovancova (Central Europe)
  2. Leonid Vlasenko (Ukraine-Moldova-Belarus)
  3. Nino Tsereteli (Caucasus)
  4. Maram Azizmamadov (Central Asia)

A list of Steering Committee members subject to rotation in the General meeting:

  1. Alla Asaeva (community of PWUD)
  2. Viktoria Lintsova (community of PWUD)

Schedule of elections:

  • From 27 August, 2018 to 16 September, 2018 – nomination process (3 weeks). Candidates are submitting their applications to become a member of the Steering Committee
  • From 17 to 30 September, 2018 – online voting to elect Steering Committee members in four above-mentioned regions and from the community of PWUD
  • 1st October, 2018 – announcement of the results.

We are inviting all EHRA members from the above-mentioned regions to submit applications to become a member of the Steering Committee until 16 September 2018.

The requirements for the candidates are: 

  1. be a member of EHRA;
  2. demonstrate readiness and ability to work responsibly and actively as a Steering Committee member;
  3. follow the principles listed in the Association Steering Committee Regulations;
  4. to reside within a region participating in the current elections;
  5. to avoid a potential conflict of interests, candidates cannot be representatives of Association’s donor organizations.

IMPORTANT INFORMATION FOR THE CANDIDATES! According to the Regulations of the Steering Committee of EHRA, a country represented in a particular region may have only one representative in the Steering Committee who is elected through regional elections (Regional Meetings). This means, that members from Czech Republic, Ukraine and Kazakhstan can’t apply for the SC elections.

Representatives of the community of people who use drugs represent the Association’s whole geographical area and should be from different countries. So we are inviting all EHRA members, who represent community of PWUD to apply to SC elections, to represent community of PWUD.

If you have any questions, please do not hesitate Secretary of the Regional meetings Eliza Kurcevic, on e-mail:

TBEC case study on the impact of Global Fund transition on the region (procurement in Georgia)

Georgia has a low HIV prevalence and decreasing incidence rates of tuberculosis (TB), indicative of strong leadership and collaboration between partners to fight the two diseases. However, there remains an increasing number of HIV cases in key populations, including people who inject drugs and men who have sex with men, treatment outcomes remain unfavorable for people with TB and there are high rates of drug-resistant TB, for which treatment outcomes are poor.

Global Fund has provided financial assistance to Georgia’s national HIV/AIDS Programme since 2003 and the National TB Programme since 2005. Global Fund plays a crucial role in ensuring access to treatment, including allowing Georgia to procure quality assured, affordable drugs through pooled procurement mechanisms, such as Global Fund’s Pooled Procurement Mechanism for HIV and the Global Drug Facility (GDF) for TB. Georgia was recently re-classified as a lower-middle income country (LMIC) by the World Bank, despite GDP per capita gradually increasing in recent years, and this could impact its co-financing requirements with Global Fund after the current 3-year funding cycle ends.

This case study explores how Georgia and the Global Fund have acted to ensure that transition from Global Fund funding does not compromise stable procurement of TB and HIV commodities and access to medicines, in terms of both continuity and scale up. Georgia has been successful through early planning, collaboration with partners and many other reasons explored throughout this case study.

Please find the full version of the case study here.

Kyrgyzstan: “Fine for freedom”

Authors: Olga Belyaeva, Advocacy Manager, EHRA/Sergei Bessonov, “Harm Reduction Network” Association, Kyrgyzstan

“Don’t push us into the corner or we will shoot”. Who pushes people into the corner introducing new Criminal Codes under the guise of “humane reforms” and reducing the prison population in Kyrgyzstan while three grams of hashish are subject to a fine of 4000 dollars?! If you don’t pay the fine they’ll put you in prison for up to 5 years. And most importantly, how can we change the vector of drug policy toward regulation of psychoactive substances, safe drug use with adequate restrictions that keep people in the legal field and give possibilities of comfortable drug use?

This is the topic of our meeting during the Dialogue Platform “Challenges for the communities and definition of responsive measures”, organized by the Kyrgyzstan Harm Reduction Association with assistance from the Eurasian Harm Reduction Association and AFEW Kyrgyzstan.

Platform discussion topics: geopolitical relations between countries, stigma influenced by religion, the history of cannabis and opium in Kyrgyzstan. How and why did people change the methods of substance use, real risks and consequences of such actions and how can we respond to them in our harm reduction programs. In fact, we see that programs and approaches of harm reduction services are not in the same street with the actual needs of people. We also discussed the pilot project that would start in one of the districts in Bishkek in 2019, based on the LEAD model and led by AFEW. The basic indicators of the desired results of the pilot are community monitoring, including  street lawyers / public defenders, personal contacts, statistics monitoring of drug related cases in police, probation and courts.

The country is currently reviewing the Government Regulation № 543 on drug quantities: small, large and extremely large. Small quantity qualifies for a misconduct, while large and extremely large quantities are considered a criminal offense. Small quantities will remain in the Regulation, for example, a small quantity for heroin is up to 1 gram.  The big step forward is that the expertise on the drug purity was included to the Regulation. Basically, it’s a good topic to consider.  If a person is detained with 1.5 grams of a drug, the person perpetrates the Criminal Code, which means 4 000 dollars fine or a prison. Then, the expertise might show that the pure substance is less than one gram, this means the person breaks the law of the Misdemeanor Code and can be subject to a fine of 800 dollars and a restriction of freedom for 6 months (the person would also be banned from visiting certain places or will be subjected to treatment according to their consent and at their expense). The problem in this case is that the actual situation on the drug stage is not taken into account, where the minimum purchase of heroin begins at five or ten grams.

“Fine for freedom” (c). People who feel and understand their freedom may create such slogans.  And we know that our message will be convincing only if we accept ourselves as people for whom the use of psychoactive substances is a standard of living.  We should expose to the thinking people the causal relationship between bribes, provocations, blackmail by policy and suicide, homelessness, pain and all negative consequences of repressive drug policies, which could have been prevented.

1 000 dollars are spent for incarceration of one person per year while opiate substitution therapy and needle exchange programs cost only 280 dollars and give you freedom. Drug policy and appropriate use of public budget are two halves of the same objective: decriminalization as a step towards the regulation of substances and redirection of resources from repression to helping people with drug dependency. Tomorrow the participants of the Dialogue Platform will clarify the strategic goals and tactical plans to blaze a trail to freedom and implementation of the constitutional rights in their country.

Connecting NGO and communities representatives from Eastern Europe and Central Asia with 3 Delegations to the Global Fund Board

The session on “Connecting NGO and communities representatives from Eastern Europe and Central Asia with 3 Delegations to the Global Fund Board” was held in the The Global Fund Community Zone of the Global Village at the XXII International AIDS Conference (AIDS 2018) on 25 July, 2018.

Continue reading “Connecting NGO and communities representatives from Eastern Europe and Central Asia with 3 Delegations to the Global Fund Board”

“Money Can Buy Health If You Budget For It”: key results of the project

In January 2016 consortium of three regional networks’ three year project was supported by Robert Carr civil society Networks Fund (RCNF) to build the capacity of community-based organizations of key populations, foster exchange and partnership between different ISP groups in budget advocacy and HIV resource accountability, help them advocate for national and municipal budgets resources to be allocated to continuum of HIV care for all ISP in EECA. During project duration joint advocacy activities and community strengthening to expand funding for and accessibility of services for people who use drugs (PWUD), men who have sex with men and all trans* people (MSM and TG) and people living with HIV (PLHIV) along the continuum of HIV care in Eastern Europe and Central Asia (EECA) region were held on regional and national level.

Main achievements on regional level

EHRA worked on the budget advocacy capacities development, ECUO has been instrumental in developing advocacy plans for the communities and delivering guidance on PR and communication tools. ECOM on the other hand has launched its issue based inter-sectoral platform – Regional Platform on Policy Reform (RPPR), which consists of regional development partners and regional networks, national actors from state and civil society. This enables communities to come up with the joint strategy on how to find new and effective approaches to MSM and trans people health in EECA region.  We strive to achieve situation in which all members bring in unique expertise and input.

The Regional Community Action Plan was developed with leadership from ECUO based on research and consultation with community representatives, regional networks and other stakeholders and serves as the basis for joint planning and fundraising.

In April 2017 EHRN organized the budget advocacy training in Kyrgyzstan for 28 participants from regional and national consortiums. As a result 28 community members were trained and then practically involved in advocacy on regional and national level.

The tool for community led assessment of access and quality of services was developed in close cooperation with national consortiums and then approbated by them in the first year of the project.  Gaps in access to services identified by the communities, were then addressed in their advocacy work. It is planned to collect and try to unify all the existing methodologies of community led assessments during the Reginal methodological expert workshop in October, 2018.

Budget advocasy guide for community activists (BA guide short) developed by EHRA on the basis of conducted regional and national trainings for different communities is a great tool to share gained experience with members of regional networks and community leaders in EECA.

Our work together as a consortium made clear the necessity and all of the potential benefits of consortiums as a model for effective national and regional advocacy. That is why the specific training was organised and methodological guidelines (“We are different but act together”) were developed to summarize best approaches and to provide communities with practical recommendations on how to build effective consortiums working in budget advocacy.

Together with 6 other regional networks consortium members launched joint “Chase the virus, not people!” campaign at AIDS 2018 conference. EHRA, ECOM along with ECUO were the coordinating parties of the campaign. The aim of the campaign is to draw attention to the problems of key population groups, against the backdrop of the catastrophic situation with the HIV/AIDS epidemic in EECA for comprehensive support of the region by the world community. Increase the priority of actions to overcome the discrimination and stigmatization of vulnerable and communities – as a key condition for an effective response to the HIV epidemic in EECA countries.

National level

While the perfect model and mode for transition from donor to domestic funding is yet to be discovered, there have been decisive steps taken in a number of countries to improve the situation. We work with our community organizations within each consortium individually and try to look at the situation in relation to all ISPs in the country at large. This enables building a win-win partnerships, raising stronger voice for change, gives consortia more influence on decision making level, including on funding of ISP services.

In June, 2016 members of the PUD, PLWH, MSM and transgender communities from Armenia, Kyrgyzstan and Estonia gathered together at the training “Budget advocacy and assessment of investments and priorities related to HIV prevention, diagnostics, treatment and care”, learned about the project and agreed on joint actions to collect and analyze investments and priorities related to HIV services.

In 2016 MSM, PLHIV and PWID communities from Armenia, Kyrgyzstan and Estonia conducted community led monitoring of HIV related survices, presented the results to relevant stakeholders and formulate strategic plans of national consortiums based on it.

Armenian consortium prepared the “Armenian civil society opinion on government readiness for transition to state funding”. Transition processes in the country have been advancing recently and consortium members are involved in them.

In Kyrgyzstan PLHIV, LGBT and PWUD community organizations are widely represented in the platforms that have their say on national HIV response. They are part of discussion during planning national HIV program which include transitional and reforming state procurement mechanism for ARVs.

As the result of the community mobilization, it was possible to recruit a group of new activists for the PWUD community in the North-East of Estonia. The core group of PWUD activists gained access to the resources of community assessment and mobilization in the summer of 2016. By the end of 2016, it was possible to register an NGO based on the initiative group. 
Estonian consortium has been actively engaged with National Institute of Health Development to work on more community based and low threshold programs for ISPs. Technical assistance provided by ECUO helped national consortium develop National Advocacy Plan of the Estonian communities.

Handle with Care: How to Document Human Rights Violations among the Most Vulnerable Groups of Key Populations

On 24 July, 2018, EHRA and Canadian HIV/AIDS Legal Network conducted a workshop “Handle with Care: How to Document Human Rights Violations among the Most Vulnerable Groups of Key Populations”.

Continue reading “Handle with Care: How to Document Human Rights Violations among the Most Vulnerable Groups of Key Populations”

Criminalization of drugs, health and human rights in the CEECA countries: what is the goal of civil society?

On 26 July, 2018, at the 22 International AIDS Conference in Amsterdam, EHRA hold a consultation on the areas of drug policy reform in the Central and Eastern Europe and Central Asia (CEECA) region.

Continue reading “Criminalization of drugs, health and human rights in the CEECA countries: what is the goal of civil society?”