Collective NTLEP’s technical team efforts and coordinated support of Leap Local Advisors enhance DR-TB detection in Malawi
The detection of Drug-Resistant Tuberculosis (DR-TB) cases in Malawi had remained persistently low, with an average of 30 patients per quarter, as reported through the quarterly TB/HIV supervision. This challenge was primarily driven by limited coverage of Drug Susceptibility Testing (DST) among tuberculosis (TB) patients. Despite advancements in diagnostic technologies such as GeneXpert, programmatic data showed that overall access to Rifampicin DST remained below 60% among bacteriologically confirmed TB cases.
Evidence from the DR-TB survey showed that the prevalence of Isoniazid (INH) resistance was on the rise in Malawi, but DST coverage for INH remained significantly lower and highly centralized. Additionally, the coverage of DST was inequitable, with rural and underserved areas—where the burden of TB is often highest—having disproportionately lower coverage rates. Compounding this issue was the inadequate capacity for programmatic and clinical management of DR-TB among healthcare workers (HCWs) to diagnose, treat, and manage DR-TB cases effectively. The majority of HCWs needed more specialized training in areas such as first- and second-line DST, the administration of second- line treatments, and the management of adverse drug reactions. Despite these capacity gaps, there needed to be a systematic mechanism to provide ongoing capacity building on the job. The three LEAP advisors in Malawi regarded these gaps as a top priority, requiring a coordinated health system approach to enhance DST coverage and HCW capacity.
To address these challenges, the National TB and Leprosy Elimination Program (NTLEP) leadership and the DR- TB team, with the technical support of LEAP advisors, conducted a programmatic gap analysis to identify priority bottlenecks in ensuring effective DST coverage and the capacity for clinical management of DR-TB. Drawing on their extensive experience in providing on-site mentorship to healthcare workers (HCWs), the DR-TB advisor, the NTLEP DR-TB team, and other core technical team members identified capacity gaps among HCWs. These included suboptimal compliance with DST testing, limited knowledge of new guidelines, and insufficient skills in designing appropriate treatment regimens. The gap analysis led to the development of various targeted interventions aimed at improving case detection. This approach required aligning financial resources with the availability of the necessary commodities for diagnosing and treating DR-TB patients.
Under the leadership and guidance of the NTLEP Manager, the Global Fund Advisor, in coordination with NTLEP’s Care and Treatment Officer, provided oversight for the implementation of in-country activities, specifically for intensive on-site mentorship under the USAID-funded TB Implementation Framework Agreement (TIFA) mechanism. The Procurement and Supply Chain Management (PSM)Advisor, in collaboration with the NTLEP PSM team, supported the revision of quantification processes in anticipation of a potential increase in commodity consumption. Additionally, they ensured the timely availability of relevant technology to support the decentralization of Drug Susceptibility Testing (DST) services.
The PSM and Global Fund Advisors supported the mobilization of funding through Global Fund grants—Grant Cycle 6 (GC6) and the COVID-19 Response Mechanism (C19RM)—to procure essential TB commodities and 50 ten-color MTB/XDR machines for DST testing. In collaboration with the National TB Reference Laboratory (NTRL) team, the ten-color platforms were strategically deployed to various parts of the country, significantly improving geographic coverage and expanding access to DST for both INH and second-line TB medicines.
All the advisors attended various NTLEP-convened sessions to orient District Health Management Teams on new guidelines and supported healthcare worker (HCW) training sessions. Together with NTLEP’s DR-TB team, the DR-TB advisor provided technical assistance (TA) during nine rounds of on-site mentorship and supported monthly virtual clinical meetings. During these sessions, the PSM Advisor facilitated specialized training on active drug safety monitoring and management.
Through this collective effort involving all LEAP advisors, the NTLEP technical team, and zonal mentors, 212 health facilities were covered. A total of 110 TB officers and nurses, 81 clinical mentees, and 21 mentors were reached and empowered to effectively diagnose and manage TB, including ensuring compliance with national DST guidelines.
Throughout the implementation, NTLEP, with TA support from the Global Fund Advisor, maintained oversight on milestone tracking and ensured the timely submission of quality deliverables under TIFA. As a result, NTLEP successfully coordinated and managed the flow of funds, resulting in a 98% fund absorption rate. Meanwhile, the PSM team, with TA from the PSM advisor, ensured an uninterrupted supply of commodities at the facility level, including the accelerated distribution of 10-color cartridges. As a result, all diagnosed patients were placed on the relevant treatment during the reporting period.
The collaborative efforts included expanding the GeneXpert network to 248 platforms, introducing 10-color-based reflex testing, strengthening sample transportation systems, and improving healthcare workers’ awareness of DST for priority groups. Resource mobilization and oversight were ensured through milestone-based tracking under the TIFA mechanism, addressing capacity gaps in the programmatic and clinical management of DR-TB. All advisors attended a monthly meeting with the USAID mission and HQ Backstop, providing key updates on thematic areas. Similarly, the advisors facilitated a monthly check-in call with NTLEP, USAID/TIFA/JSI on the implementation of all USAID-funded TIFA grants.
As a result of coordinated NTLEP teamwork and targeted interventions
- DR-TB case detection significantly increased from 25 cases in Q3 2023 to 57 cases in Q3 2024.
- DST coverage among new bacteriologically confirmed TB cases rose from 69% to 79%, while previously treated cases increased from 76% to 92%.
- DST coverage for all notified TB cases improved from 46% in Q3 2023 to 55% in Q3 2024.
- Additionally, the detection of INH mono-resistant cases surged from 3 in Q3 2023 to 36 in Q3 2024, marking substantial progress in TB diagnostic and treatment efforts.
