To mark World TB Day 2015, Friends spoke to Dr. Eliud Wandwalo, Senior Disease Coordinator for Tuberculosis at the Global Fund. From his office in Geneva, Dr. Wandwalo highlighted progress in the fight against tuberculosis as well as some of the most pressing challenges.
Friends: In your opinion, what are some of the challenges right now in the fight against tuberculosis?
Eliud: One of the major challenges has been the large proportion of estimated tuberculosis patients (33 percent or three million out of nine million total cases) that go undetected each year, resulting in continued mortality, transmission and growing drug resistance. The theme of this year’s World TB Day, “Reach the 3 Million: Reach, Treat, Cure Everyone” reflects this problem. We must draw attention to the need for a continued global commitment to finding, diagnosing, treating and curing tuberculosis, and accelerating progress toward ending the epidemic by 2035.
In addition, new and potent strains of tuberculosis are emerging that are resistant to available antibiotics, posing a major, accelerating global health risk. Multidrug-resistant tuberculosis (MDR-TB) requires a lengthier and more difficult treatment and can be 200 times more expensive than traditional treatment regimens— a drain on any nation’s health budget. Extensively drug-resistant tuberculosis — a severe form of multidrug-resistance to the disease — responds to even fewer available medicines.
Another critical challenge is the deadly combination of HIV and tuberculosis; each fuels the progress of the other in infected patients. Tuberculosis is the leading killer of people living with HIV; about one in four deaths among people with HIV are due to tuberculosis. Those who are HIV-positive are up to 30 times more likely to develop active tuberculosis than those who are not.
Friends: What is the Global Fund’s commitment and level of impact in the fight against tuberculosis?
Since its inception, the Global Fund has helped to accelerate case detection and successful treatment of tuberculosis. Global Fund-supported programs have detected and treated 12.3 million cases and treated 150,000 people for MDR-TB. The organization provides the vast majority of all international financing, approving more than $4.9 billion in grants to fight the epidemic since 2002.
Friends: What progress has been made in recent years?
Eliud: Despite the challenges, great progress has been made in reducing cases and deaths. Between 1990 and 2013, global mortality and prevalence rates fell by 45 percent and 41 percent respectively. Access to care also expanded significantly; between 2000 and 2013, 37 million lives were saved globally. Implementation of HIV/TB collaborative activities has also advanced. An estimated 48 percent of notified tuberculosis patients had a documented HIV test result in 2013 — up from 40 percent in 2011. In Africa, where the HIV/TB co-infection rate is highest, 76 percent of tuberculosis patients knew their HIV status — up from 69 percent in 2011.
There is also encouraging progress to report regarding collaboration between national governments and civil society organizations. Historically, tuberculosis was a disease addressed largely by the public sector. Now, with platforms such as the Global Fund’s country dialogue process, we have seen an increased level of engagement with civil society.
Friends: The Global Fund requires countries with high co-infection rates of tuberculosis and HIV to submit a single concept note that presents integrated and joint programming for the two diseases. Can you tell us why that decision was made and the impact that it has had?
Eliud: Despite the fact that the two diseases are so interconnected, national programs to fight them have traditionally been siloed. Of the 41 high tuberculosis burden countries, 38 were required to develop joint HIV/TB concept notes as part of the Global Fund’s funding model. The objective is to enable greater impact and appreciate efficiencies between the programs. Taking a holistic approach will help to create better alignment.
As a product of this joint programming, understanding of tuberculosis by the HIV community — and vice versa — has increased greatly. There is closer coordination and better alignment of interventions, in the hopes of increasing efficiency and achieving greater impact on those affected by both diseases. Joint programming also improves alignment of cross-cutting interventions and coordination of common procurement of commodities, such as GeneXpert, helping to avoid duplication. In addition, all programs will now be reporting on the same indicators.
The feedback we are getting from countries that have gone through this process is very good. More are submitting joint HIV/TB concept notes. In fact, some countries where these are not required have opted to submit them by choice.
Friends: What are some of the innovations that you are seeing in the fight against tuberculosis?
Eliud: There are some exciting updates in drug development. Bedaquline, for example, is the first new tuberculosis drug to be developed in more than 40 years. Though more trials on the drug are underway, it is already touted as an important addition to existing second-line drugs. In addition, Delamanid received its first global approval for the treatment of MDR-TB in the European Union for use in combination with optimized background therapy. It is also under review in Japan.
The aforementioned GeneXpert is a powerful and affordable rapid diagnostic tool for tuberculosis that was endorsed by the WHO in December 2010.
Friends: Can you speak to the collaboration between the United States and the Global Fund in the fight against tuberculosis? How are the two organizations complementing one another?
Eliud: The U.S. government plays a significant role in efforts to combat global tuberculosis through the Centers for Disease Control and Prevention (CDC), the National Institute of Allergy and Infectious Diseases (NIAID) and the U.S. Agency for International Development (USAID), among others. The CDC provides technical assistance and program monitoring and evaluation in countries with high disease burden and limited resources. The NIAID supports the development of diagnostic tools to assist in early detection, as well as research to prevent, diagnose and treat tuberculosis and HIV co-infection. USAID is working with 28 countries worldwide to improve services and prevent the spread of the disease.
Beyond funding, the Global Fund and the U.S. government work together to identify gaps in national tuberculosis strategies. By coordinating resources and activities, we collectively help to fill holes, and ensure that donor funding is not duplicative and activities are aligned with countries’ National Strategic Plans. USAID often partners with the Global Fund as an implementer of grants and by providing technical assistance on the ground.
Friends: What do you see as the future of the fight against tuberculosis?
Eliud: We are at a unique time in tuberculosis control. With the availability of new technologies to diagnose the disease and advances in implementation, we will change TB’s trajectory. There is no question that tuberculosis is one of the world’s top health challenges, with 9 million new cases and nearly 1.5 million deaths each year. But the past decades have shown what is possible when we work together. We must remain determined and engaged and work to address some of the systemic issues inhibiting progress. But if partners continue their commitment to find, treat and cure all people with tuberculosis, we can accelerate progress and reach the bold goal of defeating the disease by 2035.
 The Global Fund Results 2014
 WHO, Global Tuberculosis Report 2013 at xi.
 WHO, Global Tuberculosis Report 2013 at 13.
 WHO, Global Tuberculosis Report 2013 at xii.
 WHO, Global Tuberculosis Report 2013 at xii.
 U.S. Centers for Disease Control and Prevention, CDC’s Role in Global Tuberculosis Control (2012), 2.
 U.S. Dept. of Health and Human Services. National Institute of Allergy and Infectious Diseases, NIAID’s Role in Addressing TB, Drug-Resistant TB, and TB in People with HIV/AIDS (2007).