1. The Mexican Experience ACSM Subgroup meeting Cancun Mexico November 30 th, 2009

2. TB in Mexico 2008 18,172 new cases (TB all forms) 83% pulmonary TB=15,017 Ratio women:men 1:1.6 574 prevalent MDR cases (difficult access to treatment schedules) 20% of TB cases associated to Diabetes 10% of total are pediatric cases 19 years and younger 8% co-infection TB-HIV/AIDS 2,141 deaths in 2007 (TB all forms) Morbidity 14.1 Mortality 1.77

3. SOLUCION TB Project Overview and Objectives Mitigate stigma and discrimination Increase TB detection, treatment and cure Develop a person centered care model working with Persons Affected by Tuberculosis (PATB) Document the collaborative model and best practices

4. Initial Needs Assessment Results Policies, norms in place Strong national capacity for TB control Strong state capacity (in some cases) Less strong at jurisdiction or local levels (data analysis, technical capacity) ACSM not well developed (often confused with health promotion) Little collaboration with HIV or Diabetes (and other programs) Almost non existing collaboration with other programs or outside health sector No PTB involvement or society involvement in TB. Stigma and discrimination present Disease affects everybody, but more devastating to those more vulnerable

5. Recruitment and training of exclusive TB staff (DOTS workers primarily) Advocacy, Communication and Social Mobilization Capacities of health workers, PATB and affected communities SSA Strengthening DOTS WORKERS ACSM PATB Strategies Used

6. Santa Ana Caborca Cd. Juárez Chihuahua Creel Torreón Saltillo Monclova Monterrey Guadalupe Hidalgo Sta. Catarina Reynosa Matamoros Tampico Veracruz Poza Rica Coatzacoalcos Tuxtla Tapachula Comitán Costa Istmo Tuxtepec Acapulco Lázaro Cárdenas Apatzingan Morelia Zapopan Tlaquepaque Guadalajara Zacatecas Ojocaliente Fresnillo Participating Health Jurisdictions Tijuana

7. About the Strategies The Capacity Building component of the project included a Needs Assessment and a Capacity Building Process. The project invested about 1 year for the strengthening of capacities of state and jurisdiction level TB Programs. SOLUCION TB utilized capacity building methodologies, ACSM interventions and technical workshops, training over 900 health workers trained in its first year of implementation, across the 13 states. TB DOTS Workers: The project recruited, trained and deployed over 130 DOT workers exclusive for TB, distributed across the 13 states, in 35 priority jurisdictions. Project management was coordinated by a core team of 4 management members, and supported by 5 administrative/financial staff. A state level coordinator existed for each of the 13 states. State coordinators were responsible for day to day operations and supervision of TB-technical and ACSM activities.

8. Key ACSM Activities ACSM initial trainings. About 350 Secretariat of Health workers were trained in basic ACSM concepts, definitions and principles. Development of ACSM state plans. Training of National TB staff in ACSM planning. Implementation of ACSM activities at local level including: high level and municipality level advocacy presentations and requests; TV, radio and print media coverage, beyond World TB Day and with participation of PATB.

9. First ever stigma and discrimination survey (to validate instruments and asses community’s perception on HIV-TB stigma) in collaboration with USMBHA/UTEP KAP Survey –with TA from PATH and funding from USAID, KAP survey is in process now. In collaboration with USMBHA and UTEP One qualitative study (focus group) to assess perception of ‘Person Centered Approach’ Indicators from PTB and HW. Development and sharing of multiple ACSM materials (tool-kit) including clinical TB and ACSM Photodocumentation of TB stories through Voices and Images (Photovoice) Projects; Nuestra Casa ACSM Project; Que se Escuchen las Voces Key ACSM Activities (2)

10. TB Diagnosis, Treatment and Cure Project Results

11. Total # of people with respiratory symptoms studied; 2 nd semester comparison 2007-2008 Source: Sistemas de Información en Salud SIS

12. Pulmonary Tuberculosis Cases Diagnosed: 2 nd Semester Comparison 07-08 Source: Plataforma Modulo de TB/DGE/SSA, 2009

13. Cure and Abandonment Rates: 2007-2008 Comparison Source: Plataforma Modulo de TB/DGE/SSA

14. State-Level TB Control Indicators DX and CURE ACHIEVEMENTS IN 13 STATES SUPPORTED BY USAID Priority State 200420062008Expected 2009 % Dx% Cure% Dx% Cure% Dx% Cure# Dx# Cured Baja California76.358.310063.1100.074.0969824 Chiapas52.564.982.621.2100.084.7336286 Chihuahua88.27010056.5100.071.6900765 Coahuila10087.110051.9100.085.3409348 Guerrero10081.110059.9100.088.5804683 Jalisco10077.510053.4100.087.8389331 Michoacán10072.410043.383.384.8219186 Nuevo León49.860.910050.3100.087.4699594 Oaxaca51.8653440.3100.082.5557473 Sonora75.368.810056.199.581.8538457 Tamaulipas7978.910078.497.284.1746634 Veracruz53.479.810083.5100.087.71,4141,202 Zacatecas1007043.895.5100.076.05950 Subtotal 8,0396,833 Nacional75.875.3 1006498.784.011,87510,094 Source: Presentation by M. Castellanos NTP Director

15.  Greater involvement in TB by NGOs working in HIV/AIDS  Joint TB-HIV ACSM activities  Training and follow-up  Integrated person-centered approach  Promotion of 4 I’s of TB-HIV  Increased/improved planning and collaboration with Diabetes programs Future Activities

16. Is important to engage and maintain the highest quality standards of diagnosis, treatment and care from a medical standpoint; and it is essential that TB not be overly ‘medicalized’. Person- and community- centered aspects should be effectively combined with the more medical aspects in a comprehensive manner. ACSM efforts can not be successful without engaging PATB, not as recipients or victims or even as patients, but as decision makers, advocates, peers, highly valuable resources, and keys to ultimate success. ACSM activities should have a clear purpose and be related to TB control realities and goals. The implementation of ACSM with the full participation and creativity of health personnel will result in a transformational experience for them, facilitating the provision of integrated, person-centered health services. Lessons Learned and Recommendations

17. The introduction of ACSM activities with the full participation and creativity of health personnel will result in a transformational experience for them, facilitating the provision of integrated, person-centered health services. Even though DOTS, ACSM, and certainly TB, have been around for a long time, there are innovative ways to carry out successful strategies. It is critical to ensure TB workers have an opportunity and are encouraged to document and share their experiences. It is important that resources are devoted to rigorously documenting and providing an evidence base in order to transform some of these ‘promising’ practices into ‘best’ practices. Strategic partnerships are essential for success, maximizing resources, promoting sustainability, and optimizing social mobilization around issues of stigma, discrimination, gender inequalities, and other key social drivers of TB. Recommendations (2)

18. www.soluciontb.org Thank you - Gracias