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echnicians in new National Reerence Laboratory in ashkent, Uzbekistan.

Context

Tis report describes the approach o German Development

Cooperation (GDC) in supporting national eorts to reduce

the impact o B and B/HIV co-inection in Georgia and

Uzbekistan whose experience is broadly representative o that

o ve other countries beneting rom this approach in the

southern Caucasus (Armenia and Azerbaijan) and central Asia

(Kazakhstan, Kyrgyzstan and ajikistan).

In 2008, more than 9 million people worldwide became sickwith tuberculosis and 1.8 million died, the highest death

toll o any curable inectious disease. About hal a million o

those who died were also co-inected with HIV. Multidrug-

resistant B (MDR-B) and extensively drug-resistant B

(XDR-B) were also on the rise in many parts o the world.

Few world regions are as threatened by B and HIV, diseases

that thrive in the presence o the other, as eastern Europe and

central Asia: B prevalence is up to 50 times higher than in

western Europe, and multidrug-resistant B prevalence rates

are among the highest in the world. Widespread injecting drug

use, high rates o incarceration, serious poverty and a declinein health services immediately ater the disintegration o

the Soviet Union have raised ears that countries here could

be on the cusp o explosive dual epidemics o B/HIV.

In Georgia (population 4.4 million) the number o B patients

notied increased rom 32 per 100 000 inhabitants in 1995

to 97 per 100 000 in 2002. In Uzbekistan (population 27

million), notications increased rom 43 to 81 per 100 000

over the same period. Notication rates in both countries con-

tinued to increase, though at a slower pace, until 2006, beore

beginning a gradual decline.

B-drug resistance, however, continues to rise in Georgia and

Uzbekistan. In Georgia about 6.8% o all newly diagnosed

B cases and 27.4% o previously treated B cases were

multidrug resistant, according to 2010 gures rom the World

Health Organization. In Uzbekistan the comparable gures

are 14.2% and 49.8% respectively. HIV has also been in-

creasing and in 2007 prevalence among adults (15 49) was

estimated to be 0.1% in both countries.

Healthy dividendsHow German investments are helping to stop TB and HIVin the Caucasus and central Asia

To download the full version of this report andother publications in this collection, go towww.german-practice-collection.org

German HIV Practice Collection

This Collection describes programmes supported by German

Development Cooperation assessed as promising or good

practice by experts from German development organiza-tions and two international peer reviewers with expertise

in the particular eld. Each report tells the story, in plain

language, of a particular programme and is published in a

short (four-page) and full version, often with links to related

tools and reading at our web site. This Collection aims to

stimulate dialogue, so please tell us what you think and rate

them, at this address: www.german-practice-collection.org.

Managing Editor (ghpc@giz.de)

In the last two decades, ortunately, the global community has

demonstrated a growing commitment to addressing the dualthreat o B and HIV. United Nations Millennium Develop-

ment Goal 6, or example, calls or measures to have

halted by 2015 and begun to reverse the incidence o both

B and HIV, and the WHO/Stop B Partnership is overseeing

eorts to meet the tuberculosis part o this target.

GermanHIVPractice Collection

8/9/2019 Healthy dividends: How investments by Germany and partners are helping to stop TB and HIV in the Caucasus and

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Te Stop B Strategy calls or a range o actions in six areas to

Pursue expansion and enhancement o high-quality DOS

(directly observed treatment, short-course);

Address B-HIV, MDR-B and other challenges;

Contribute to health system strengthening;

Engage all care providers;

Empower people with B and communities; and

Enable and promote research.

Approach

German eorts to address B in the southern Caucasus and

central Asia go back more than one decade and ocus on invest-

ments to catalyze health-system strengthening, rather than

direct technical assistance. Te support is provided through

KfW Entwicklungsbank(KW Development Bank, one o the

main instruments o GDC) and in the last decade has provided

about 65 million euros or B programmes here. GDC/KW

programmes help countries to implement the Stop B Strategy

in ve areas: building national B programmes; twinning and

technical assistance or laboratories; protecting prisoners; org-ing regional networks; and working in dynamic partnerships.

Building national TB programmes

Direct GDC involvement in providing steady supplies o qual-

ity assured drugs and other essential medical commodities

has helped Georgias National B Programme (NP) and

Uzbekistans Republican DOS Center (which administers the

NP) ensure appropriate treatment o B patients nationwide.

Tis support has been conditional, tied to governments dem-

onstrating a growing commitment to the Stop B Strategy and

DOS, a cost-eective way to reduce the burden o B and

B/HIV with generic procedures and standard equipment.

As well as drugs and commodities, DOS calls or swit,

reliable case-detection and bacteriological analysis. GDC has

invested heavily, thereore, in helping the NPs o Georgia

and Uzbekistan build B laboratory inrastructure and

networks. As a result Georgia, or example, now has a well-

developed network o laboratories, with a National Reerence

Laboratory (NRL) in bilisi, a regional laboratory at the

West Georgia Center or uberculosis and Lung Diseases, 30

rst-level microscopy laboratories and 37 sputum collection

points. It also has state-o-the-art equipment, a reliable systemor transporting sputum samples or drug-sensitivity test-

ing, and is now building and equipping a new NRL to allow

or, among other procedures, rapid diagnosis o multi-, and

extensively, drug-resistant B. Uzbekistan has made similar

progress.

With greatly expanded capacity, the NPs o Georgia and

Uzbekistan are now recognized as the main coordinating

and implementing agencies and have inuence in shaping

government investments in B and HIV services.

Twinning o reerence laboratoriesGDC has also ocused on building capacity and operational sup-

port to assure the quality o work o Georgia and Uzbekistans

national reerence laboratories. It has done this by twinning

them with two WHO-certied, supranational reerence labo-

ratories based in Germany: the National Reerence Center

or Mycobacteria, in Borstel; and the Supranational Reerence

Laboratory at the Institute o Microbiology and Laboratory

Medicine, in Gauting.

Experts at Gauting, or example, have given technical supportto Uzbekistans NRL to build a new laboratory in ashkent,

in accordance with international biosaety standards, helped

Georgian patient with multidrug-resistant B taking his medicine at bilisi DO Spot.

Patients at the Abastumani B hospital, Georgia.

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train sta in culture and drug-resistance testing and introduced

standard operating procedures or quality assurance systems.

Experts rom Gauting have also visited the ashkent laboratory

three times a year (2007 2010) and ashkent technicians

have visited Gauting to urther develop their skills. As a result,

Uzbekistans NRL now meets international standards and is

disseminating its expertise regionally.

Protecting prisoners with the Stop TB Strategy

GDC has supported the International Committee o the Red

Cross (ICRC), the NPs and prison health authorities toextend the Stop B Strategy to prisons, so that prisoners

receive state-o-art services or prevention, treatment and care

or B, multidrug-resistant B and B/HIV coinection.

ICRC has also helped establish systems that ensure that

prisoners continue to receive care on release. Tis means that

Uzbek prisoners with multidrug-resistant B who are not

yet cured at time o release now go directly to a specic ward

o the Republican B hospital in ashkent, until cured.

Forging regional networks o health proessionals

With WHO Regional Ofce or Europe, GDC has organized

regular conerences and workshops or health proession-

als (decision-makers and programme managers, as well as

doctors, nurses and technicians) throughout the two sub-

regions to increase political commitment and strengthen

human resources or B and HIV services. Tese sessions have

likely boosted transparency and expedited the expansion o

high-quality DOS regionally. In the southern Caucasus, the

meetings have also ostered exchanges among proessionals

rom countries recently at war with one another, contributing

to peace-building.

Working in dynamic partnerships

Te GDC approach has helped NPs develop and coordinate

productive partnerships with bilateral and global agencies such

as the Global Fund to Fight AIDS, uberculosis and Malaria,

KNCV uberculosis Foundation, Mdecins sans Frontires,

ICRC, United Nations Development Programme and USAID.

Georgias NP used partnerships such as these to become the

rst ormer Soviet Republic, outside the Baltic region, to oer

universal access to treatment or multidrug-resistant B.

Results

GDC is only one o many partners local, national and

international engaged in boosting the response to B and

HIV in the southern Caucasus and central Asia, so it is di-

cult to attribute epidemiological trends and systemic impacts

to specic interventions. Some data and anecdotal evidence,

however, indicate that GDCs approach is helping Georgia

and Uzbekistan protect their citizens against these potentially

devastating diseases.

While incidence rates or all orms o B rose markedly in the

two countries rom 1990 2000, they levelled o in the rst

decade o the new millennium. As well, B case notications

have been declining in recent years. As a result, both coun-

tries may already have surpassed the B target in Millennium

Development Goal 6.

Both Georgia and Uzbekistan now have strong national B

programmes, with steady supplies o essential medicines and

robust B laboratory networks. Uzbekistans Deputy Minister,Marat Khudaykulovich Khodjibekov, or example, has said

that GDC contributed greatly to the strengthening o the

Decision-makers at central Asian B Conerence on MDR-B, ashkent, 2008.

Nursing providing drugs or patients with MDR-B in ashkent Hospital, where also

ex-prisoners on MDR-B treatment directly go ater completing their sentence.

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Republican DOS Centre with its sustained and thorough

planning procedures and long-term commitment to the

cause. According to WHOs B advisor or central Asian

republics, Gombogaram sogt, the ashkent National

Reerence Laboratory is now the best in central Asia and

GDCs strengthening o capacity o B laboratories has been

one o the most important contributions towards scaling

up MDR-B and B/HIV programmes.

Tere is also widespread agreement that Germanys regional

approach to addressing B and HIV, by orging internationalnetworks o dedicated health proessionals, and extending

B services to prisons has been worthwhile. Te Director

o Georgias NP, Iagor Kalandadze, or instance, says that

Germanys long-term support or the introduction o rst-line

B drugs and other contributions have helped to halt the

spread o the B in his country.

Lessons learnt

GDCs approach highlights, among other, lessons:

Regional networks o health proessionals, such as those

supported by GDC, boost cooperation and capacity and,

in regions characterized by conict, may contribute to peace;

Partnerships require national coordination (e.g. by NPs) as

well as care in choosing the right partners or specic tasks; and

Political commitment can be increased by tying nancial

support to concrete actions by governments.

Peer review

According to the expert reviewers o the ull version o this

report, Richard Zaleskis o WHO Regional Ofce or Europe

and Masoud Dara o KNCV uberculosis Foundation, the

GDC approach summarized above is a promising practice

in that it is transerable, innovative, participatory and empow-

ering (o national authorities, and health proessionals) and

cost-eective (though ormal studies o this have not yet

been done). Regarding other standard German HIV Practice

Collection criteria, they note:

Efectiveness: GDC has contributed to B and HIV

control across the southern Caucasus and central Asia withquality-assured microscopy and culture/DS laboratories,

improved B-case detection, eective monitoring and

evaluation and inormation exchanges among countries.

Contacts and creditsMain contacts or the described

approach:

In Germany: Peter Re,

KW Entwicklungsbank

E peter.re@kw.deIn Georgia: Iagor Kalandadze,

Executive Director, National Center

or uberculosis and Lung Diseases

E iagor.kalandadze@tbgeo.ge

In Uzbekistan: Gulnoz Uzakova,

Manager o Project Implementation

Unit (B) o Global Fund to Fight

AIDS, uberculosis and Malaria

E g.uzakova@dots.uz

Published by:

Te German HIV Practice Collection

Responsible: Tomas Kirsch-Woik

Deutsche Gesellschat r Internationale

Zusammenarbeit (GIZ) GmbH

Dag-Hammerskjld-Weg 15

65760 Eschborn / Germany

E ghpc@giz.de

I www.german-practice-collection.org

Contact at Federal Ministry or

Economic Cooperation and

Development (BMZ):

Dr. Simon Koppers, Section 311

E simon.koppers@bmz.bund.de

Writers:

James Boothroyd, Katarina Greield

Design and production:

www.golzundritz.com

Photos:

Pawel Sapunow (ashkent);

Ane Gogichadze (bilisi and

Abastumani)

All individuals whose images appear

in this document consented to be

photographed.

Eschborn, July 2010 (this edition

January 2011)

Quality o monitoring and evaluation: KW Entwick-

lungsbank conducts regular monitoring missions, on

occasion with WHO. As well, the annual conerences

organized or all republics in central Asia and the southern

Caucasus, contribute substantially to the monitoring

and evaluation o B control in the countries.

Sustainability: Most interventions backed by GDC have

been adopted by national governments and/or nanced

by the Global Fund to ght AIDS, uberculosis and Malaria

and, thereore, are likely to be sustained over time. As well,

the partnerships supported by KW, technical as well asnancial, enhance the sustainability o B and HIV pro

grammes described here.

Acknowledgements

Tis report was made possible by contributions rom many,

including the reviewers, see above, and those listed under

Contacts and Credits. Special thanks to Iagor Kalandadze,

National Center or uberculosis and Lung Diseases, bilisi;

Maia Kavtaradze, Global Fund to Fight AIDS, uberculosis

and Malaria (B component), bilisi; Gulnoz Uzakova, GlobalFund to Fight AIDS, uberculosis and Malaria, ashkent;

Kazim Mukhamedov, KW B Programme, ashkent; and

Pierpaolo de Colombani, WHO Regional Ofce or Europe,

Copenhagen.

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