On April 21, 2016 in Ministry of Health of Ukraine was held the working meeting of all the stakeholders involved in the development of a national targeted social program to combat tuberculosis in the 2017-2021. The program of the working meeting included discussion the development of the outpatient treatment system of TB patients in Ukraine.

The meeting was attended by Director of the Public Health Department of the MOH of Ukraine S. Ostashko, representatives of the WHO Office in Ukraine, Chairman of the commission to terminate the SI “Ukrainian Center for Social Disease Control of the Ministry of Healthcare of Ukraine” N. Nizova, managers of international projects in the field of combating tuberculosis USAID, PATH, ICF “Alliance for Public Health”, Abt Associates, representatives of TB services in Donetsk, Vinnitsa, Poltava, Sumy, Dnepropetrovsk region, Kiev city, which introduced the pilot model of outpatient treatment of TB patients, representatives of the National Institute of Tuberculosis and Pulmonology of F. Yanovsky and representatives of the public organization “Social movement “Ukrainians against TB”.

With a welcoming statement to participants of the meeting appealed: Director of the Public Health Department of the MOH of Ukraine S. Ostashko, Director of the treatment, procurement and supply management department of ICF “Alliance for Public Health” S. Filippovych, medical adviser for TB, MDR-TB, TB / HIV activities of the WHO Country Office in Ukraine A. Slavuckij. Each of the speakers emphasizes the importance of joint efforts by all stakeholders for the preparation of high-quality national program.

The participants discussed the concept of health financing reform in Ukraine and the preliminary results of development of the new system of TB services’ financing.

Project Manager: TB Advocacy Y. Chorna, ICF “Alliance for Public Health” presented the aims and objectives of the regional project “TB in Eastern Europe and Central Asia Project on Strengthening Health Systems for Effective TB and DR-TB Control » (TB-REP).

The head of the public organization “Social movement “Ukrainians against TB” V. Rudenko acquainted all participants with the objectives of the advocacy strategy for the implementation of outpatient TB treatment models in Ukraine within the framework of the regional project TB-REP.

Representatives of TB services in the pilot regions of Ukraine presented the results of the implementation of outpatient treatment models of TB patients, the basic steps, barriers and suggestions to overcome them.
Participants of the meeting expressed their understanding of the need for determination and establishment of best practices experiences and their reflection in their national target social program to combat tuberculosis in the 2017-2021.

Presentation of the TB-REP project at the national level

Discussion of the experience of implementing the outpatient TB treatment models in the regions

In April 2016, the World Health Organization issued the updated Guidelines for the screening, care and treatment of persons with chronic hepatitis C infection.

The first version of the Guidelines was published in 2014. Since then, new direct acting antivirals (DAAs) have been introduced, allowing to improve cure rates up to 90% or higher, minimize side effects and shorten the duration of treatment.

In the updated version of the Guidelines, the peginterferon and ribavirin regimens were replaced with regimens using new-generation DAAs (taking into account specifics of certain patient groups). Telaprevir and boceprevir, as well as their combinations with peginterferon and ribavirin, are no longer recommended for the treatment of chronic hepatitis C.

Ludmila Maistat, Senior Programme Manager: Hepatitis/HIV Policy and Advocacy in Alliance for Public Health, who is a member of the WHO Strategic and Technical Advisory Committee for Viral Hepatitis, participated in the development of 2014 Guidelines as well as their updated version.

It is expected that the Guidelines will be regularly updated with the introduction of new drugs and regimens.

You may find the policy brief here.

On 13-17 April 2016, Barcelona hosts an annual meeting of the European Association for the Study of Liver (EASL) – International Liver Congress, ILC 2016.

 Every year, this Congress is attended by over 10,000 participants: doctors, hepatologists, scientists, representatives of pharmaceutical companies, microbiologists, and government officials of the member states. This event is a great opportunity to share professional achievements and develop effective strategies.

Ludmila Maistat, Senior Program Manager: Hepatitis, Alliance for Public Health presented the results of the effective work to expand access to HCV treatment in Ukraine and in EECA region. Significant updates and important comments to the presentation on the access to treatment were made by Professor Olga Holubovska, the main independent infectious disease doctor of the Ministry of Health of Ukraine, head of the infectious disease department of the Bogomolets National Medical University.

Tetyana Barnard, Project Manager: HCV Treatment, Alliance for Public Health also took part in the Congress as a part of the Ukrainian delegation.

Within the Congress, members of the Ukrainian delegation will take part in a number of meetings with key partners and international stakeholders with a view to expand Alliance programs in Ukraine, strengthen cooperation with partners and develop a plan of further steps.

Two advisory committees met in Copenhagen, Denmark, on 4–5 April 2016 to guide new action plans on HIV/AIDS and viral hepatitis for the WHO European Region.

The importance of this rigorous consultation process was highlighted, especially for the action plan on viral hepatitis, as it is the first plan on the prevention and control of viral hepatitis in the WHO European Region.

The aim of the new HIV/AIDS and viral hepatitis plans is to boost efforts to achieve zero new HIV and hepatitis infections, zero discrimination and zero AIDS-related deaths in the region.

52 experts, representing ministries of health, national HIV and hepatitis programs, civil society organizations, academia, United Nations agencies, major partner organizations, WHO headquarters, country offices and WHO collaborating centers took part in the discussions.

At the advisory committee, Ukraine was presented by Ludmila Maistat, Senior Program Manager: Hepatitis, Alliance for Public Health and Professor Olga Holubovska, the main independent infectious disease doctor of the Ministry of Health of Ukraine, head of the infectious disease department of the Bogomolets National Medical University. Alliance for Public Health cooperates with the Ministry of Health to expand access to the effective programs of treatment for members of key vulnerable groups as well as general population, to develop a new National Program of Hepatitis Treatment for 2017-2021 in line with the new WHO recommendations and to strengthen cooperation at the national and regional levels.

Ukrainian representatives were part on the advisory committee which prepared an action plan for the European region, which was developed at the World Health Assembly and will be adopted in May 2016.

You can learn more about the meeting here

http://www.euro.who.int/en/health-topics/communicable-diseases/hivaids/news/news/2016/04/europe-shapes-new-action-plans-on-hivaids-and-viral-hepatitis

In March 2016, the first phase of the Project “Scaling up accessible and effective HCV treatment through community-based treatment model for most vulnerable populations in the resource-constrained Ukraine” was successfully competed. Meanwhile, recruitment of patients for the second phase of the project is underway.

Since June 2015, 450 patients representing key populations got access to HCV treatment in 11 healthcare facilities within the first phase of the project, which is 80% more than the planned indicator. Increasing the number of treatment courses available was possible due to the use of pegylated interferon procured within the state budget, which allowed reducing the duration of treatment to 12 weeks and increasing the number of courses.

As of 1 April 2016, 183 new patients received access to hepatitis C virus (hereinafter – HCV) treatment within the second phase of the project, and thus the total number of patients covered with treatment is 633 people.

93% participants of the first phase had HIV, and 94% of them received ART. 80% were people injecting drugs, with 8% of them being OST program clients. 15% of project participants had previous treatment failures when treated with two-component regimen: pegylated interferon + ribavirin. The success of innovative treatment is proved with sustained virological response observed in 90% of patients.

List of criteria for enrolment into the second phase of the project, list of healthcare facilities offering HCV treatment and NGOs providing support to patients may be found here.

Today, on April 6th, 2016, the Mayor of Kyiv Vitaliy Klitchko signed the Paris Declaration of commitment to fighting AIDS making Kyiv one of 60 cities globally that took this commitment. The declaration was initiated by the Mayor of Paris and UNAIDS in 2014 and sets the plan to achieve the 90-90-90 HIV treatment targets by 2020, which will rapidly reduce new HIV infections and AIDS-related deaths and put the world on the Fast-Track to ending AIDS by 2030.

Today the HIV situation in the city of Kyiv is critical. Out of the estimated 32 500 people with HIV in Kyiv only some 11 700 are registered with AIDS facilities, which is 1 in 3 HIV-positive persons knowing his/her status. Only 5000 are accessing ART in Kyiv.

‘There is a strong need to substantially improve case finding in Ukraine’s capital, broaden and decentralize ART and reinforce prevention programs for men who have sex with men – the group where the HIV epidemic is actively developing and where coverage of prevention interventions is low’, says Tetiana Deshko of Alliance for Public Health.

Alliance for Public Health applauds the initiative of the Kyiv municipality and of Mayor Klitchko. Alliance has been supporting AIDS response in Kyiv for decades through the Global Fund program providing annually 34 Million Hryvnias for HIV, Tuberculosis and Hepatitis C prevention, care and treatment programs using the network of HIV-service organizations and healthcare facilities. Annually, some 25 327 (81% of estimated PWID in Kyiv) PWID, 7 145 (67%) sex workers and 12 922 (36%) MSM are reached with these programs, with some 2.1 Million syringes, 2.9 Million condoms distributed for free annually.

Alliance together with Kyiv municipality led the predevelopment of the regional Concept Note to the Global Fund on HIV/TB responses among key populations in the cities of Eastern Europe and Central Asia. Mayors of the 12 cities of the 10 countries in the region joined Kyiv leadership in commitment to responding to AIDS in this funding request.

On 24 March 2016, activities dedicated to the World TB Day were held almost all over Ukraine with support of Alliance for Public Health, calling to Unite to End TB.

About 15 CSOs played an active role in the campaign. To draw public attention to the issues of TB, raise awareness in TB prevention and early detection, information materials were distributed thought mass media and awareness-raising classes were held, including lectures for students of professional and higher educational institutions, and individual counseling on early TB diagnostics was conducted.

About 3,500 copies of information materials “Tuberculosis” and “Tuberculosis is Curable” were distributed and about 2,500 people were screened with the help of special questionnaires for presence of tuberculosis symptoms. In case of detecting any people with tuberculosis-like symptoms, recommendations were given on the need to seek medical assistance in treatment facilities.

Alliance for Public Health was featured in a case study included in a new advocacy brief for community-led organisations ‘Advancing combination HIV prevention’, produced by the International HIV/AIDS Alliance and UNAIDS. The publication aims to support community-led organisations make the case for greater investment in HIV combination prevention at national, district and local levels.

The case study highlights how Alliance for Public Health supported Kenyan AIDS NGOs Consortium and its partners in Kenya harm reduction programme development within Dutch-government funded project Community Action on Harm Reduction in 2011-2015. The project improved access to HIV prevention treatment and care for people who use drugs, their partners and children; advanced their rights; and increased the capacity of civil society and government stakeholders to deliver harm reduction and health services to communities of people who use drugs.

‘Practical, effective tools that have proved efficient in Ukraine have been swiftly taken to practice in Kenya. When we are thinking about how fast-track can be achieved in AIDS, horizontal exchange is one of the most effective solutions. Alliance Centers* that accumulate technical knowledge is a good example of facilitating horizontal exchange’, says Andriy Klepikov, Executive Director of Alliance for Public Health.

Full publication is provided during Civil Society Hearing in New York this week, and can be downloaded here.

*Alliance Centres of Practice have been set up by International HIV/AIDS Alliance to bridge the gap between evidence and practice in order to end AIDS. All Centres are hosted by Alliance Linking Organisations. They draw on their individual expertise to connect, bring together and develop the Alliance’s collective knowledge, experience and community links on specific expert areas. Alliance for Public Health hosts the Centre on HIV, Hepatitis C and Drug Use. More information on Alliance Centres available here: http://www.aidsalliance.org/centres.

On 5 April 2015, Alliance for Public Health (Alliance) together with its partner civil society organizations held Hepatitis C: Game of Survival campaign near the premises of the Cabinet of Ministers of Ukraine. Participants of the campaign demonstrated the “deadly slot machine” to policy-makers and mass media, demanding to solve the urgent problem of allocating budget funding to treat patients with hepatitis C virus (HCV).

According to the official data, there are 73 thousand patients with HCV registered in Ukraine, among them at least 40 thousand urgently need treatment. However, those numbers do not reflect the real situation with the spread of epidemic. As estimated by WHO, more than 5% of people in Ukraine are infected with HCV, which is over 2 million people! It is hard to say how many of them should have already received treatment. There is no official register of patients, though it should be established in accordance with the National Viral Hepatitis Program.

Back in March, people living with HCV, doctors, and civil society organizations were looking for the results of the long-awaited government competitive bidding to procure drugs for HCV treatment, as there was a hope that after international organizations take over the procurement, innovative treatment will become more accessible. However, the bidding results have not been made public yet, and even the expected amount of drugs will cover only a minor share of patients. 6.1 thousand bottles of the modern drug, sofosbuvir, planned to be procured with government funding, may be enough to cover 2,000 standard treatment courses! Such number of patients who will be able to receive treatment will no way help to eliminate the HCV epidemic in Ukraine. According to the best-case scenario, only one of 20 patients who urgently need treatment today, will be able to receive the therapy within the government funding. Patients’ selection criteria should first and foremost depend on the severity of disease, but in practice the existing corruption schemes may make certain adjustments in the selection procedures.

People living with HCV unwillingly became hostages of a very dangerous game, and now their fate depends on the “deadly slot machine” – some of them will be lucky to receive treatment which will give them a chance to survive. Meanwhile, thousands of other patients will not live to see the next round of the slot machine operation! Delays and half words from the side of the Government, the Ministry of Health, and regional administrations make patients and treatment advocates go out on the streets. These days, similar campaigns will also be held in many regions of Ukraine to make responsible public officials review budgets and allocate additional resources to procure treatment courses from local budgets. In 2014-2015, in Ukraine only about 100 patients had a chance to receive treatment at the cost of regional budgets, but unfortunately it is typical when even regions with budget surplus, where over 10 thousand people are registered living with HCV, local authorities count only on the national funding of such treatment. At the same time, there are success stories of regions with budget deficit, which apart from the courses allocated within the National Program, also find a way to procure life-saving treatment within their competence. Most heads of regions count on the funds allocated within the National Program and on the treatment courses provided by Alliance. But such approach is self defeating and extremely ineffective – programs of international donors will be shut down next year, and the National Program will be over in December 2016. Thus we have a paradoxical situation when there is nobody who cares about patients. And the treatment program is available only on paper in order to report on its existence, and even if the program is implemented, it is often done “for the sake of appearance” and not to really save thousands of lives!

“Current HCV treatment is very expensive, in developed countries it may cost up to USD 80,000 per course, – underlines a community activist, Julia Dorokhova. ¬– Today the innovative drugs have already been registered in Ukraine, and hundreds of patients were able to get treatment within the Alliance program. But now we have all found ourselves in a situation when we are players in a “state casino” – nobody knows if any money will be allocated for treatment, if policy-makers will remember about tens of thousands of patients or if they will go on thinking that there is no epidemic of HCV? It is not enough to just approve a program, when people’s lives are at stake”.

At the same time, in the center of Kyiv a mobile clinic was operating, where all people could receive professional counseling on HCV diagnostics and treatment as well as special forms for examinations.

“Not a single country in the world knows the exact number of people infected with hepatitis C virus, because the infection process is hidden, – says Professor Olha Holubovska, Head of Infectious Disease Department at the Bogomolets National Medical University, chief infectious disease specialist of the Ministry of Health of Ukraine. – Our consolidated efforts allowed to approve the National Viral Hepatitis Program as well as 16 regional programs; introduce amendments to the treatment guidelines, which were brought in line with the international standards; and register innovative direct-acting antiviral agents in our country. Now Ukraine has to develop new modern strategies aimed at elimination of viral hepatitis in line with WHO objectives. That is why we are currently working on those tasks together with civil society organizations. Unfortunately, the level of funding of the National Program is very low, with many activities not financed at all. Also, not all regions of the country demonstrate sufficient commitment in this regard – even the existing local programs are either not financed at all or are financed at an extremely low level. To comply with the WHO Global Strategy, it is not enough to provide only treatment – this strategy also stipulates improvement of the epidemiological surveillance system, implementation of prevention activities, etc. If we stop at this stage, further spread of HCV epidemic will have disastrous consequences for Ukraine”.

So far treatment of HCV depends on the operation of the “deadly slot machine”, allowing only one in twenty patients to win a chance to receive life-saving treatment within the state budget. But will this machine operate at all or will the statesmen just forget about tens of thousands of patients waiting for their therapy? The situation with HCV epidemic becomes more and more pressing. The countdown of people’s lives in this Live Casino is going on…

***

Over 150 million people in the world are infected with hepatitis C. The threat of the spread of epidemic in Ukraine grows in the context of the economic crisis and military conflict in Eastern Ukraine. One of the priority areas of the activities of Alliance for Public Health and its partners is response to the epidemic of hepatitis C in Ukraine and provision of HCV diagnostics and treatment for vulnerable groups and general population. In 2015, Alliance launched the first program of treatment with a new-generation drug – sofosbuvir, which is expected to cover up to 2,000 people. 203 patients have already completed their treatment courses. As per the set standard, 12 weeks after completion of the therapy patients are to go through a follow-up examination – and it shows that in 90% of those who receive treatment HCV is undetectable. This is a huge step forward as compared to the old treatment regimens (peginterferon + ribavirin), when the indicator of successful treatment outcome was no more than 50%. In 2014, Alliance managed to negotiate significant price reduction with the manufacturer, which allowed for the first time in Ukraine to procure sofosbuvir at the price of USD 900 per course.

24 MARCH IS A WORLD TB DAY

Today, every fourth person with tuberculosis (TB) remains unnoticed by our national healthcare system! Due to the lack of minimum conditions required for early TB detection in the context of the military conflict in the East of Ukraine, the development of TB epidemic is now uncontrolled like a “black hole”, which is a real threat for other regions of the country, especially considering high level of migration and big number of internally displaced persons. This is a catastrophe which should be in the focus of attention of policy-makers, government officials and national media!

Recently, a tendency is observed in Ukraine and in the world of further transmission of the forms of tuberculosis not sensitive (resistant) to most traditional drugs. Ukraine ranks fifth in the worldaccording to the prevalence of multidrug resistant tuberculosis (MDR-TB)! According to the results of the first national epidemiological study, the level of MDR-TB among newly diagnosed patients is 22.0%, and among people with recurrent cases of TB – 55.6%.

Ukraine still has the worst in Europe TB cure rates – only 71% of newly diagnosed TB cases and 34% of MDR-TB cases are cured.

The main activities of International Charitable Foundation “Alliance for Public Health” (hereinafter – Alliance) as a co-recipient of the Global Fund to Fight AIDS, Tuberculosis and Malaria (hereinafter – Global Fund) in countering the TB epidemic are aimed at its early detection among members of key populations and providing effective treatment to patients with MDR-TB.

In 2015, almost five thousand patients with MDR-TB received drugs and social support withsupport of Alliance; in total, it is planned to provide treatment courses to 9,300 patients.

Alliance implementing partner in support of patients with MDR-TB who receive outpatient treatment is the Ukrainian Red Cross Society (hereinafter – Red Cross). Cure rates of the patients who receive medical and social support of the Red Cross with the help of Alliance are encouraging: cure rates went up to 89.6% as compared to 32% among the patients who did not receive such support. Thus, social support of patients and forming adherence to treatment are as important for eliminating the epidemic as financing of TB treatment.

If the cost of a treatment course for drug-sensitive tuberculosis is $35, the cost of MDR-TB treatment is about $2,200, which is 62 times higher! Providing access to high-cost TB treatment for members of key populations is one of the key tasks of Alliance. Since 2012, we have been procuring drugs for treatment of patients with MDR-TB, and the scope of our procurement has been increasing every year. Thus, in 2015 drugs were procured in the total amount of USD 11.7 million, which will allow providing treatment to 5,250 patients or half of all MDR-TB patients in Ukraine.

Nine percent of MDR-TB patients develop side effects, which often result in treatment termination. To minimize the number of patients who drop out of treatment and to prevent development of drug-resistant TB forms, last year Alliance for the first time procured medications to eliminateside effects for all MDR-TB patients who needed them, which is very important to improve their quality of life.

The situation with tuberculosis treatment in Ukraine is aggravating due to the outdated approach to patients’ hospitalization. The average period of hospital stay is 90 days, while according to WHO data most patients are no longer dangerous to people around them three weeks after they start their therapy, and they can switch to outpatient treatment. So their isolation in inpatient units is not justified. Alliance also promotes modern approaches to TB treatment that should be first ofall patient-oriented, which stipulates expansion of outpatient service delivery models, case management practices, and multidisciplinary approaches to meet social and psychological needs of the patients.

Despite considerable restrictions of the activities of humanitarian organizations in the temporarily occupied territories in the East of Ukraine, in 2015 Alliance conducted six successful deliveries of humanitarian consignments, including 23 thousand packs of TB treatment drugs. Aggravation of the epidemic situation in the East of Ukraine is more and more critical. For example, the numberof cases of active TB forms even in Ukraine-controlled areas of Luhansk oblast grew by almost30%, in particular among children and adolescents – 2.3 times! As for the incidence of TB/HIV co-infection, its level increased almost 30% among the general population of Ukraine-controlledareas of Luhansk oblast. There are no official data related to the areas not controlled by Ukraine. The war in Eastern Ukraine led to the creation of some kind of a “black epidemic hole”, which may become a source of transmission of socially dangerous diseases in Ukraine. Alliance plans to provide further support to 14 partner civil society organizations in Donetsk and Luhansk oblasts, which work to provide early TB detection among the key vulnerable populations.

Alliance implements TB programs not only in Ukraine, but also in other countries of WHO European region. Thus, January 2016 was a starting point of the first three-year regional project “Strengthening health systems to effectively control TB and MDR-TB in Eastern Europe and Central Asia”. Alliance together with TB Europe Coalition is one of the leading partners involved into implementation of the project, focusing on its vital component – coordinating and uniting efforts of partners and stakeholders. In particular, this component is aimed at uniting the efforts of CSOs to advocate for the development of outpatient care systems with high-level efforts aimed at reforming healthcare systems to increase the effectiveness of TB control in target countries.

On the occasion of the World TB Day, the Alliance for Public Heals calls to policy-makers andresponsible government officials of all levels not to delay reforms of healthcare systemsnecessary to implement patient-oriented approaches in the delivery of timely and high-qualitymedical and social support to TB patients!