Global advocacy for all the Three I’s: “Push”
“Advocacy has to happen at all different levels,” said Cynthia Eyakuze. “At the global level, within the national level — the policy makers, the providers and the patients themselves. And there’s very different types of advocacy, including campaigns going onto demand creation, etc.”
A 3 I’s communications strategy should be developed to generate the pressure and demand globally. Immediate steps include distributing the report on the meeting’s outcomes to WHO staff at all levels, discussing the meeting’s outcomes at upcoming STAC and STAG meetings, WHO regional technical advisory group meetings, and to plan regional or country level 3 I's meetings.
The meeting outcomes are already being promoted at all major upcoming meetings (UNAIDS PCB, PEPFAR, the June 9th UN meeting, World AIDS Conference).
“We need to promote the dissemination of successful and best practices. There are good things happening in some parts of the world; we have to communicate and disseminate them,” said Dr Getahun. “There must also be scientific advocacy, using existing scientific literature and enlisting major medical journals to promote TB prevention, diagnosis and treatment in general for people living with HIV.”
Technical experts from other agencies (KNVC, Union, JICA) should be engaged — champions and skeptics alike. In particular, an advocacy and communication strategy to tackle the misconceptions/perceived obstacles to IPT implementation is crucial.
Advocacy “Pull”
Donors and global community groups need to work together to generate grass roots demand for the Three I’s.
“This is the first time that I’ve actually heard the “push and pull” mechanism being applied to clinical services and I think it is important because the “pull” from the community of TB patients, has historically been lacking in the TB programme, compared to the HIV programme, where I think it was very effective in getting a lot of changes made,” said Dr Alwyn Mwinga of the CDC Global AIDS Program in Zambia.
“Community activist groups and PLWA groups have not yet done enough to educate their peers and create demand,” said Mark Harrington. “This is related to the fact that TB is still a stigmatised disease.”
But that is changing, as evidenced by the first-ever activist march for TB during the World Union on Lung Health in Cape Town which involved over 5000 people. And more and more HIV activists are being trained to become HIV/TB activists.
HIV/TB activists at the Geneva meeting are clearly taking on the Three I’s as part of their own agenda.
“We [TAG] recently did a training for 45 activists from 25 different countries on TB science literacy — they were really excited about it and people do want to know the science behind all of this. There are now some really professional activists operating at a very high level. So when you are developing policy… I really urge you to engage with the community because they’re your greatest advocates in terms of helping to push your research and your programs into policy into programs and implement action,” said Claire Wingfield of TAG.
“We should empower people living with HIV/AIDS to understand symptoms of TB and ask for care, ask for screening for TB,” said Dr Alyssa Finlay of the CDC. “TB stigma can be addressed through education and awareness. Community, national leaders and role models should promote TB screening and address the issue of TB stigma. There should be simple, clear, positive messages that intensified TB case finding is part of the package that gives you the best care possible.”
This positive spin is crucial — rather than the usual negative messages about TB.
“We’ve got to make sure there’s a very positive message about TB because it empowers action,” said Dr Gilks.
Human rights activists should be engaged as well by putting TB prevention in a human rights-based context. For example, Mark Harrington described the failure to implement IPT as a clear human rights problem.
“Failure to provide IPT which prevents TB, which causes the most deaths from HIV, is a violation of human rights. IPT could help 10.3 million people with TB/HIV co-infection right now. And the fact that we’re not doing it is a grave violation - I believe - of their rights to life and [treatment] with a cheap effective drug,” he said.
Likewise, people with HIV have a human right to safer healthcare facilities. Reverend Phillips suggested legal action might even be in order:
“I really believe a couple of great malpractice lawsuits would do well for a few ministries of health! It may never happen in the world, but I really think a few great lawsuits would wake up the Ministries, and then maybe they’d do something!”
Large-scale information education and communication campaigns for TB prevention, diagnosis and treatment need to be launched targeting HIV and TB in the family. “Health providers should ask patients about family members when they come to their clinic visits,” said Dr Finlay, “and screen them as well.” In addition, she suggested that education about TB should be integrated into schools to mobilise children.
Dr Ndwapi Ndwapi of Botswana suggested using the interaction with clients in ART clinics as an opportunity for public education — because while they in the waiting room, they are a captive audience.
The community of healthcare workers also needs to be engaged. Demand for TB IC and prevention also needs to created among the healthcare workers, who often initially see implementation of the Three I’s as “extra work.”
“Most of our workers are overburdened so when we look at this approach, we should make some room to say, ‘How are we going to support our workers?’” said Dr Sálomáo.
At the same time however, healthcare workers need to be convinced that implementation of the Three I’s is in their own best interest.
“I would suggest that all the 3 I’s activities are in support of the workers because the workers are at risk for TB, many of them are infected with HIV and many of them will develop TB,” said Dr Reuben Granich of WHO. “So I think that this effort is very much about worker safety and worker rights and supporting these overburdened healthcare workers.”
Dr Dick Chaisson of Johns Hopkins Medical School pointed out that in the US, an outbreak of TB in a health facility in Florida “led to a huge demand from healthcare workers for safe environments. If you’re talking about community mobilisation for IC, the healthcare worker community has to be mobilised and just as the patients have to demand IPT, they have to demand IC. It’s an untapped source of incredible power that needs to be utilised to address the issue!”
Resource mobilisation
Implementation won’t happen without resources — additional human resources will need to be recruited and trained to work on this issue as part of raising HIV care, standards and implementing the 3 I’s. Finally, the meeting participants called for the 3 I’s should be prioritised in the upcoming GFATM round 8/9 proposals, and in the upcoming PEPFAR country operational plans. Funding partners should be urged to direct funding toward infection control activities, including renovations and refurbishments.
Even before the Three I’s meeting concluded, many of the meeting participants made commitments to promote the Three I’s agenda — including representatives from many of the funding partners. These can be read in full at the end of the official Three I’s meeting report: http://www.who.int/entity/hiv/pub/meetingreports/art_hivtb_meeting_april2008/en/index.html