305 courses of capreomycin from Eli Lilly, a donation of cycloserine from the Chao Foundation, and paser from Jacobus. These resources, in addition to the leveraged expertise, were key in removing bottlenecks to drug procurement from the Ministry of Health. When GLC drugs finally arrived, in-country expertise in treatment and management of MDR had been established, allowing rapid adoption.
The Ethiopian/GHC MDR TB treatment partnership has been scaled up and was expanded to Gondar in northern Ethiopia in August 2010. As of July 2012, 500 patients had been initiated on therapy, with only 6 defaults and a death rate of less than 10 percent in a very sick population (24 percent HIV co-infection and the majority of patients with bilateral cavitary disease). Though some GLC-imposed procedures (e.g., requirements that patients be hospitalized in isolation wards that were not yet completed at program initiation) were extremely problematic due to lack of funding and capacity limitations, Goldfeld noted that it was possible to find “work-arounds,” such as setting up interim isolation wards in unused facilities and receiving drug donations. Goldfeld reported that scale-up of the MDR TB program, countrywide training programs, and health systems capacity building are ongoing in Ethiopia, with outstanding program results. She also noted that of the original 221 patients who were waiting for therapy in fall 2008, her team was able to find and initiate only 66 (30 percent) on MDR therapy; 42 had died waiting for drugs (20 percent), and the team was unable to find 110 (50 percent) of those on the list despite a house-to-house search, many of whom thus presumably died. She emphasized the urgency of providing access to high-quality MDR care to interrupt preventable death from a curable infectious disease and to interrupt further transmission.
Challenges of Supplying QA SLDs (MSF)32
Henkens described MSF’s role in providing MDR TB treatment worldwide. In 1999, MSF became involved with procuring SLDs. The organization committed to pooling procurement of 2,000 treatments from QA sources by negotiating a price drop with manufacturers and buying drugs to guarantee complete treatment.33 MSF currently treats approximately 1,200 patients in 17 countries, using both the GDF procurement mechanism and its own pooled procurement mechanism for certain projects. MSF maintains a stringent QA structure by adhering to the requirements for SLDs determined by
32 This subsection is based on the presentation by Myriam Henkens, International Medical Coordinator, MSF.
33 After 2,000 treatments were attained, procurement was taken over by IDA in 2002 and transferred to GDF in 2006.