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On December 17, 2020, at the virtual presentation of the regional overview “Breaking the Silence: Human Rights, Gender, Stigma and Discrimination Barriers to TB Services in the EECA region” Nonna Turusbekova, TBC Consult, co-author of the report, presented the main conclusions and recommendations of the regional overview.

She also highlighted the directions of its use and noted what makes the overview such a unique and necessary tool for everyone working in the field of CRG to advocate for reducing barriers to access to TB services in Eastern Europe and Central Asia. According to Ms. Turusbekova, “the regional overview pinpoints persistent problems demanding better solutions and scale up of pilots that have proven to be working, so that the interventions can reach all the TB affected communities.”

Over 130 participants from 39 countries took part in the virtual presentation of the regional overview, which indicates a high level of interest in the data presented by the TB-REP 2.0 team from Georgia, Tajikistan, Kazakhstan, Kyrgyzstan, and Ukraine.

Pilot to address CRG barriers are already underway, including case management, training primary health care workers, as well as engaging civil society in providing community awareness and patient education, symptoms screening and sometimes adherence support to the key populations they work with.

“From 2016 to 2020 several CRG assessments and reviews, including the Global Fund Breaking Down Barriers assessments, were conducted in the region. Last summer, we collected and analyzed the available reports, and, where applicable, the National TB strategies and the Global Fund funding requests to see if and what CRG recommendations were reflected there”, said Nonna Turusbekova.

The most common barriers identified in the overview are linked to: (1) Extreme discrimination against certain key populations; (2) Consequences of TB for women; (3) Stigmatization by health care workers; (4) People-centered approach; (5) The role of primary health care; (6) Job security and the right to work; (7) Active case finding in rural poor.

Human rights

The assessments show that people who use drugs and people with a history of detention, especially women from these key populations, appear to be the most vulnerable and stigmatized. For these key populations, any encounters with the law enforcement may result in interrupting whatever treatment they are on, which is in direct violation of their rights.

“It is especially women from these key populations, who experience higher levels of stigma and discrimination when they meet with the health care workers or the police”, said Nonna. “Solutions include integration of harm reductions, HIV and TB services and making them more comprehensive. Besides, there are many ways to improve awareness of key populations starting with informing them what services are for free, and about the rights and responsibilities of people with TB.”

Gender

In all countries the proportion of notified cases is larger in men than in women. Clearly, TB in men needs a gender-responsive approach, as part of people-centered care.

Across the board women show better adherence and better treatment results. But these are women who have to overcome larger barriers such as scarce finances, lack of family support and Gender-Based Violence (GBV).

Some of the recommendations include: first, disaggregating data by gender, providing support in case of TB and pregnancy, and breastfeeding. It would be advisable to take a family approach to supporting people with TB to address myths, identify potential barriers to adherence, and prevent violence.

Stigma and Discrimination

Stigma is often linked to a lack of, or breaches of confidentiality, and discrimination by health care workers. At the same time, many national strategies and funding requests to the Global Fund identify health care workers as one of the high risk populations. Primary Health Care workers are playing an ever increasing role in TB response, however, the reports also mention stigma which may be related to a lack of knowledge of TB and infection control and a lack of motivation, time and skills to work with clients from key populations.

Some major interventions for this barrier are improving infection control and eliminating stigma and discrimination towards health care workers who develop tuberculosis. It is also a must to adhere to maximum possible confidentiality during contact investigation.

People-centered approach

The issues and decisions related to people-centered approach remain very important. There definitely need to be more than one way to deliver treatment, and the countries are already rapidly expanding the options.

Even within any given key population, the conditions of people with TB vary and require a corresponding set of individualized interventions. For instance, the lack of childcare provisions affects women’s possibility to attend facility-based DOT. Especially during the times of COVID-19 there are difficulties receiving DOT. In some rural and remote places, DOT has not been available at all.

“The need in people-centered care, taking into account the individual’s circumstances are recognized by the countries and pilots are underway, here TB programs, can learn from the vast experience that the HIV programs have in case management”, says Nonna Turusbekova.

It is important such case management get integrated into the national standard packages of services, and are supported by state funding.

Ways to move forward and key recommendations

To be able to implement the proposed solutions, we need to increase productive collaboration, between multiple stakeholders, including civil society organizations, especially those that already work with key populations affected by TB.

“A good starting point is engaging CSOs and communities in formulating national TB response strategies and plans, then funding of their involvement in strategy implementation, supportive supervision for CSOs, and CSO participation in multisectoral accountability processes and other activities to evaluate the performance of national TB programs”, says Ms. Turusbekova. - An important observation made by one of the “Breaking down Barriers” mid-term assessments was that there is a need to continuously build up professionalism and capacity for CSOs to keep up with the pace of CRG interventions.”.

The recording of the virtual presentation is available on the PAS Center's YouTube channel.

The document was prepared by TBC Consult:Nonna Turusbekova, Kristina Zhorayeva, Peter Mok and Samanta Sokolowski. Peer reviewers: technical guidance and internal review were carried out by the TB-REP 2.0 project team, PAS Center: Stela Bivol, Liliana Caraulan, Svetlana Nicolaescu and Cristina Celan. Other contributors and external reviewers: Additional valuable inputs included in the overview were provided by the TB-REP 2.0 Global Fund Portfolio Management Team and the CRG team (Alexandrina Iovita, Bryce Bambara); Stop TB Partnership Country & Community Support for Impact Team (Viorel Soltan, Thandi Katlholo and James Malar); and WHO EURO Division of Country Health Programmes, Joint TB, HIV and Viral Hepatitis Programme (Askar Yedilbayev and Andrei Dadu).

PAS Center gratefully acknowledges the contributions of all partner organizations that supported the development of the Regional CRG Overview. Special thanks to the organizations and teams that have conducted CRG assessments and developed national reports that informed the current overview: Georgian network of people who use drugs (GeNPUD) ‘’New Vector’’ (Georgia); ALE "Kazakhstan Union of People Living with HIV" (Kazakhstan); NGO “Gender and Development” (Tajikistan) and Canadian HIV/AIDS Legal Network; Alliance for Public Health (Ukraine); United Nations Development Programme (Ukraine); TB Coallition (Kyrgyzstan); Global Fund to Fight AIDS, Tuberculosis and Malaria; Stop TB Partnership; APMG Health.

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