AIDS and TB: How should care be delivered?

EDITOR'S NOTE: The question of how to design effective health care delivery systems and interventions is one that impacts all areas of health care. A recent example of this is the case of HIV/AIDS and tuberculosis in developing countries. Efforts to lower drug prices and increase the flow of funding for international health initiatives have created new opportunities to curb the spread of disease and its toll on communities. However, increased funding does not necessarily translate into effective programs: which approaches will work best and how should funds be directed to make a maximum impact? This section of HMI World examines these issues from the perspective of AIDS and TB experts, and we invite readers to share their own insights.

Dr. Jim Yong Kim photo by Steve Gilbert

HIV and tuberculosis are pandemic, and prevention alone will not stop them. So says Dr. Jim Yong Kim, HMS professor of medical anthropology, chief of the Division of Social Medicine and Health Inequality at Brigham and Women’s Hospital, and tireless advocate for universal access to AIDS and TB medicines.

Working in Haiti and in the shantytowns of Lima, Peru, he and Partners in Health co-founder Dr. Paul Farmer take on tough medical cases—patients infected with HIV or multidrug resistant TB—and prove treatment can work even under impoverished, low-infrastructure conditions.

It has been a watershed year for international public health. Drug prices are falling. The newly established Global Fund for AIDS, TB and Malaria has collected two billion dollars, and Kim was awarded $13 million over five years from the Fund for AIDS treatment as part of a $60 million grant to Haiti. Partners in Health (PIH) has ambitious plans to extend their coverage in Haiti and they are integrating with the National TB Program in Peru to provide treatment of multidrug resistant TB (MDR TB) throughout the country. But as money and medicines become available, the urgent question is: how to ramp up delivery? Kim discussed this recently with HMI World contributing writer Anne Mahon.

AM: Should poverty be on the medical school curriculum like any other disease?

JK: Absolutely, along with inequality, history, political economy and all the other factors that impact the way disease and suffering are distributed in the world. We know, for example, that poverty and inequality strongly influence many of the behaviors that are putting the poor at greatest risk for infections with HIV. To ignore these factors in the face of the worst epidemic in 600 years would be crazy.

AM: Why not focus on prevention?

JK: The pathology of diseases like AIDS and TB are overwhelming the minimalist approach. Sticking to simple population-based, low-cost intervention has not been enough. Public health strategies in developing countries must now include drug access. And our work has shown that effective and rational treatment programs enhance prevention efforts.

AM: In Peru, PIH developed a close-to-client, community-based treatment plan for patients with multidrug resistant TB, called DOTS-Plus. This is a spin-off from the standard treatment strategy for non-resistant TB devised by the WHO called DOTS (directly observed therapy, short course). PIH has been working with the National TB program to scale up DOTS-Plus for delivery throughout Peru. What is your long-term strategy?

JK: We are investing in local infrastructure and training so that, in addition to eventually overseeing its own MDR TB program, the Peruvian government will become a prominent leader in the fight against MDR TB in Latin America. For example, we are working closely with the Peruvian National Institute of Health to turn it into the first supranational reference laboratory for TB in the world located in a poor country.

	Kim and his team have been working in the slums of Peru to develop a community- based treatment program for TB

AM: For a long time representatives from WHO and other health organizations, including the Peruvian National TB program, argued that DOTS was sufficient to contain the spread of resistant TB, and that treating MDR-TB was not a wise use of resources. Will this attitude continue to present obstacles to integration?

JK: The former director of the national program in Peru, who without question was one of the great TB program directors in history, was a DOTS purist and a real disciplinarian. He believed in basic, simple but in fact extraordinarily effective interventions. Under his leadership the national program was working with the notion that a good DOTS program doesn’t have MDR-TB. This was the ideology of the time, but it’s simply not true. There is a reservoir of resistant bacteria in the population – a legacy of poorly supervised pre-DOTS treatment efforts. The former director slowly came to understand that DOTS is not effective against these bacteria. If we can just convince some of the last few TB experts who still believe that DOTS can cure MDR-TB, we will have made a lot of progress indeed.

AM: Not only do you wish to more fully integrate your initiative with the National TB Program, but the program must expand at an accelerated pace. How are you going to do this?

JK: The next step, and the reason I’m optimistic that this can be done on a much larger scale, is that we are now working with [HMS professor and President and CEO of the Institute for Healthcare Improvement] Donald Berwick. What Don has done is borrow methods of quality improvement from Edwards Deming, a management guru from IBM. The model Deming used allowed for rapid evolution of a production system to one that works economically and efficiently to yield a quality product. Don is helping us use a similar model in Peru. Soon, we will deploy these methods in Russia, Boston and Haiti as well.

AM: In the Deming model it was essential to secure a strong commitment from management. In your case this is the government of Peru. Do you have their support?

JK: Yes. Obstacles are often systemic. That’s why the political leadership from above is so important. The president of Peru has said he’s enthusiastic. Without question we will start this improvement cycle with the full involvement of the ministry of health.

AM: How do these improvement cycles work?

JK: Don uses what he calls “breakthrough series collaboratives.” Essentially, you define a specific aim for improvement then convene a group of experts and others familiar with the system. They work together to find innovative solutions. In our case these insights might come from a community health care worker in Lima who has experience with all aspects of the problem, or an international expert on MDR-TB, or a local physician. It’s a method for sharing innovation with a large group of people in a very intensive way to speed up the learning process. Through short cycles of incremental change we can rapidly improve infrastructure.

AM: Some health care professionals believe that the most efficient way to ramp up to AIDS treatment is by using the existing health care system. Are you going to use the MDR-TB program in Peru to treat HIV also?

JK: Yes. In Haiti we’re essentially utilizing our TB program to treat AIDS patients. And I think there’s no question that TB and HIV programs have to be extremely closely intertwined. Whether they can be the same program is a political issue and also a question of disease burden. Because the Peruvian ministry of health is trying to take apart all the vertical programs and make an integrated health system, my suspicion is HIV and TB will be very closely linked in Peru. We’ve been working closely with the ministry on both of these issues.

AM: Is the system prepared for failure?

JK: Don’t expect us to succeed the first time around. You know that’s not the way it works in the business world. But should we fail, we will know why. We will then be able to apply those insights to the next improvement cycle.

AM: To mount the effort necessary to fight global disease, you say we need the kind of national mobilization of resources and intellect that made it possible to put a man on the moon. What will it take to generate the kind of enthusiasm for international health that Americans felt for the space program in the early 1960s?

JK: The devastation. That and the innovative system we’ve adopted to rapidly integrate with the Peruvian TB program. We’re going to have health care workers sitting inside a hovel with a blue plastic roof studying a flow chart that could have come out of ALCOA. It will be the heartbreak of AIDS orphans combined with the rationality and familiarity of state-of-the-art management science that will get the money flowing. That is my hope anyway.