For dozens of years, Oksana Ponomarenko has been researching tuberculosis and implementing evidence-based strategies to treat patients and curb transmission of this global scourge. As country director for Partners In Health/Russia, much of Ponomarenko’s work is focused on hard-to-treat, drug-resistant strains of tuberculosis among vulnerable patients, including prisoners and those in the throes of chronic alcoholism and drug addiction.
Over the years, Ponomarenko and her team have forged critically important partnerships with the Russian Ministry of Health, the World Health Organization (WHO), and the Global Fund to Fight AIDS, Tuberculosis and Malaria, among many others. The findings gleaned from PIH/Russia’s work have helped shape global policy on treating multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) in community-based settings.
Before the 44th Union World Conference on Lung Health, PIH spoke with Ponomarenko about the persistent burden of drug-resistant TB, the level of accompaniment that defines PIH/Russia’s renowned Sputnik program, and the daily challenges her team faces.
Q: Can you start by giving a brief overview of the burden of tuberculosis in Russia?
The Russian Federation has the 11th highest burden of TB in the world and the third-highest burden of MDR-TB. In the wake of the collapse of the Soviet Union, the health infrastructure in Russia deteriorated dramatically, and the country faced a number of significant economic crises. This, along with high rates of penal incarceration due to increased poverty and crime rates, resulted in the spread of both drug-sensitive and drug-resistant TB.
In the face of this growing epidemic, the country was advised to focus on the treatment of drug-sensitive tuberculosis, or strains that can be treated with a standard regimen. The treatment success rate among new smear-positive cases in Russia was 55.8 percent in 2005, largely due to the alarming rates of drug-resistant TB, which was left untreated. The result is that currently MDR-TB constitutes 30.3 percent of all TB patients in the Russian Federation. The WHO classified Russia as one of 28 high-burden countries for MDR-TB (i.e., countries estimated to have had at least 4,000 MDR-TB cases arising annually and/or at least 10 percent of newly registered TB cases with MDR-TB), with an officially estimated prevalence of 31,000 cases per year.
Currently, high rates of drug-resistant tuberculosis in Russia are mainly explained by the high rates of penal incarceration, transmission resulting from the hospitalization of all TB patients in facilities with inadequate infection control measures including prisons, and poor development of patient-centered approaches to deliver outpatient care in the ambulatory sector. Thus, our main work in Russia is focused on addressing the majority of these challenges, bringing treatment and access to health services for people suffering from TB and its drug-resistant forms.
Q: In a previous interview, Carole Mitnick, a TB researcher and assistant professor of global health and social medicine at Harvard Medical School, said your work in Tomsk, Russia, is a “shining example” that’s based on a “unique ambulatory model to serve prison and civilian populations.” Can you discuss this model and its evolution?
Over the course of PIH’s work in Tomsk Oblast, the epidemiologic situation of the region has changed significantly. Compared to other regions in Siberia, the TB incidence and mortality in Tomsk have become much lower. To a large extent, it can be explained by the fact that we have developed and implemented a comprehensive model of ambulatory care for our TB patients.
Care is offered to every patient, at any place and at any time.
Care is offered to every patient, at any place and at any time. We provide care wherever it is most convenient for the patient. For example, the program Sputnik, which has operated since 2006, serves the most vulnerable patients—the homeless, and those suffering from chronic alcoholism, drug addiction, and behavioral challenges. Twice a day the Sputnik staff has to find each patient from this program, deliver the medication and make sure it’s taken properly, and distribute food packages. The cure rates of this project are up to 90 percent. Now, based on this success, we have started to see similar programs emerge in other regions of Russia.
Q: The HIV co-infection rate among Sputnik’s patients is about 5 percent, which is high compared with national and international rates. What are the major challenges to treating co-infected patients in a community-based setting?
The biggest problem lies in the fact that each health system in Russia is vertical and operates separately—TB, drug addiction services, HIV care, psychiatric services, among other health programs. On the federal level and in individual regions, or oblasts, these programs are not connected. Oftentimes clinicians in one program will not have complete information on other nearby services and programs.
In the case of the Tomsk project, from the very beginning we combined different services so they work in partnership. As a result, one of the achievements of our project is the sustained delivery of complex interventions for vulnerable patients who may not be able to travel to different facilities to get different medications.
For example, usually a newly released TB patient from the prison sector is immediately referred to a TB dispensary to complete the treatment. We have the ability to set up a TB clinic within an HIV center—or the other way around, in which HIV-positive patients can receive antiretrovirals at a TB dispensary—to make sure it is as easy as possible for the patient to receive comprehensive care. We have also incorporated psychological services and drug addiction services into our TB program from the very beginning. This interconnectedness is the foundation for our success.
Q: Can you also discuss the burden of hepatitis C among drug-resistant TB patients? Do you see any advances on this front?
The estimate for the prevalence of hepatitis C in Russia is approximately 5 million people, which is around 3 percent of the entire country’s population. In the case of our patients in the Sputnik program, between 2006-2010 up to 40 percent of TB and MDR-TB patients were co-infected with hepatitis B and C.
These patients’ chances to get access to treatment are very limited—the regimens that are on the market currently cause severe side effects and tend to aggravate treatment of dual diseases. This is a serious issue, which has remained largely unaddressed so far due to systematic problems and lack of more progressive medications.
Q: The health system in Russia is similar to health systems throughout Eastern Europe and among countries that were previously part of the Soviet Union. Do you think the successes from Tomsk can be expanded throughout the region?
The Tomsk project has served as a model not only known in Russia or Europe, but throughout the world. In 2000, when we started the DOTS-Plus [Directly Observed Treatment, Short-course] program for the treatment of MDR-TB, there were only four projects of similar nature in the world—in Peru, Latvia, Estonia, and the Philippines. The findings gleaned from these projects have been immensely valuable and continue to inform drug-resistant TB treatment programs around the globe.
Delegations from almost all Former Soviet Union (FSU) countries have repeatedly visited Tomsk in order to learn best practices and exchange information. We’ve worked with clinicians of all ranks—from chief TB specialists to nurses. Recently, we hosted a delegation of TB specialists from the Chinese Center for Disease Control and Prevention.
Tomsk has served as a training site for many TB practitioners through numerous partnerships, including one with the World Health Organization Regional Office for Europe. Our projects are referenced in numerous WHO publications—specifically, three best practices from our projects on MDR- and XDR-TB prevention, control, and care were included in a recent WHO report. Information about our projects is disseminated throughout Europe and Central Asia, especially among FSU countries. It’s inspiring to know PIH/Russia’s commitment to accompanying patients has such far-reaching influence.
Essentially, what we have done in Tomsk has now been adopted as official policy by Russia’s Ministry of Health.
Q: Over the years, you’ve authored more than 30 papers and delivered evidence-based research that has helped shape global policy on treating MDR-TB and XDR-TB. What are some of the most significant success stories and advancements you’ve seen?
As I’ve mentioned, in 2000 the project in Tomsk was a pioneer and, of course, its realization and results generated significant interest among the TB community. Research based on this project has helped prevent future mistakes in TB treatment programs, and countless patients in dozens of countries have benefitted from that.
Evidence-based research is truly important because it can facilitate appropriate policy and decision making. I would like to offer you the example of a new regulation that took effect in the Russian Federation last year: This new order, No. 1224, regulates the organization and treatment of TB patients and places specific emphasis on the ambulatory model of care. This is exactly what we have tried to show through the example of the Tomsk project—that social support and accompaniment in a community setting increases adherence. The new order draws on many aspects of the Tomsk project, including the distribution of food packages, public transportation subsidies so patients can get to the clinics, the use of community health workers who go out and visit patients, and increased monitoring. Essentially, what we have done in Tomsk has now been adopted as official policy by Russia’s Ministry of Health.
Q: The World Bank recently classified Russia as a high-income country. Does that accurately reflect the real-life situation of the patients PIH/Russia serves? Is there the need for additional assistance or attention from the Russian government and international community?
While Russia is included in the list of high-income countries, it’s important to acknowledge that there are 140 million people living in Russia, and many of them do not make a sufficient income. In our projects, we are mostly working with low-income populations. It is not a secret that TB is a disease of the poor, with harsh living conditions and insufficient nutrition worsening the burden of the disease. Many of our patients, both homeless and chronically sick, suffer from alcohol dependency.
Unfortunately, in Russia the emphasis has always been placed on the in-patient model of care. Many have thought it easier to keep a patient in a TB clinic than to offer them adequate treatment in an ambulatory setting. Fortunately, it is now becoming accepted that an ambulatory patient can be treated at home, and it is easier for the patient and significantly cheaper. It is nice to know that our work has helped policymakers realize this fact.