Tuberculosis in the Dominican Republic: addressing the barriers to sustain the achievements.

The base paper calls for urgent implementation of activities to achieve the targets for TB control set by the 1991 World Health Assembly, the 2015 Millennium Development Goals and the Stop TB Partnership. Laserson & Wells conclude that the greatest challenge is the devastating impact of the HIV epidemic. They suggest that countries will only achieve success with an accelerated political commitment to TB/HIV collaborative activities through national revised plans built upon the Stop TB Strategy and the Global Plan to Stop TB 2006–2015. The Dominican Republic faces several challenges in addressing these targets. While the incidence of all forms of TB in the Dominican Republic has been estimated to be among the highest in the Americas (91 cases per 100 000 people in 2005),1 much progress has been achieved since the implementation of DOTS in 1999. By 2005, DOTS services had been made available to 80% of the population and detection of infectious cases was 83% for the whole country and 76% in DOTS areas. The 2003 cohort analysis suggested 80% treatment success.1 Funding for TB control has been secured for the next 3 to 5 years and technical support has been provided. A steady supply of high-quality anti-TB drugs has been assured via the Global Drug Facility, fixed-dose combinations have been introduced and a MDR-TB unit has recently been created. This impressive list of achievements was realized in a short period of time. However, to ensure sustainability and guarantee that targets are reached, 5- to 10-year national planning in line with the Global Plan to Stop TB 2006–2015 and implementation of the new Stop TB Strategy are vital. The Dominican national TB programme and its partners face several of the barriers acknowledged in the base paper. Notably, the latest data suggest that progress to address TB/HIV, MDR-TB and XDR-TB has been slow. Data on TB/HIV coinfection, which are limited to certain areas of the country, suggest that between 6% and 11% of TB patients are infected with HIV.2,3 A recent survey suggests that young adults, provinces with a high rate of tourism and sugar-mill camps should be targeted for interventions.3,4 While the country has introduced some TB/HIV collaborative activities (e.g. isoniazid prophylaxis for HIV-infected people and provision of antiretroviral drugs), there are no data on the number of HIV-infected TB patients receiving antiretroviral drugs. There is no surveillance of HIV among TB patients, no information is available on coinfected patients receiving cotrimoxazole, and a proper referral/counter referral mechanism for patients has not been established. Collaboration between TB and HIV/AIDS programmes needs to advance immediately and concretely in line with the new Stop TB Strategy.5 The recent development of national TB/HIV guidelines and inclusion of TB/HIV activities on national plans are steps in this direction. MDR-TB has been one of the greatest challenges for the Dominican Republic, which was classified by WHO in the mid-1990s as one of the world’s hot spots for MDR-TB.6 This high rate of MDR was associated with poor programme performance and lack of political will to fight the disease. TB control has now been implemented according to internationally recommended guidelines for more than 7 years, and a project to manage MDR-TB has recently started. The use of second-line drugs must be fully supervised to prevent the rise of extensively drug-resistant TB. New data on the magnitude of MDR-TB is urgently needed. In addition, a strengthened national network of properly-equipped laboratories with trained personnel and a fully functioning national reference laboratory are necessary to ensure access to quality-assured sputum smear microscopy, culture and drug-susceptibility testing. Surveillance efforts in the Dominican Republic, although following WHO/PAHO standards, need to be strengthened. While case reporting in DOTS areas suggests a steady increase in the number of cases detected, nationally there is an inconsistent pattern of increases and decreases. The quality of case finding across the country and TB programme/health system issues, such as the quality of the workforce, may be contributing factors explaining disparities. The national TB programme needs to develop and maintain a strong stewardship capacity to guide and oversee collaboration between private and public providers. Public–private approaches, including monitoring and evaluation, should be explored and implemented. Increased advocacy and social mobilization to engage civil society in TB-control efforts is also needed to increase access to DOTS services in urban and rural areas. The implementation of locally relevant operational research can also be useful in identifying programme limitations and strengths, as well as mechanisms to facilitate scaling up of activities. Finally, TB-control efforts must progress hand-in-hand with strengthening of the health system as a whole. International cooperation, financial sustainability and strong political commitment to work at all levels with different stakeholders will be the recipe to achieve targets for TB control in the Dominican Republic. ■