One of the long-term projects of the Boston-based medical service organization, Partners in Health (PIH), has been the treatment of multidrug resistant tuberculosis (MDR-TB) in the Tomsk region of Siberia, Russia. Established in 2000, the program received a $1.5 million grant in November 2010 from the United States Agency for International Development to expand its services to five additional Russian regions: Novosibirsk, Altai Krai, Saratov, the Republic of Mari-El, and Voronezh.
Initially, the MDR-TB treatment program in Tomsk was created to curb one of the world’s most persistent epidemics of drug-resistant tuberculosis. Over the years, the project has evolved to address patient care needs more broadly, to train local health professionals, and to conduct research to improve treatment across Russia as a whole.
Today, through an exchange program created by PIH, Russian medical professionals can earn masters degrees in public health at Harvard. The first graduates of the program are now sharing their knowledge as lecturers at the Moscow Medical Academy.
Dr. Alex Golubkov is the current medical director of the PIH program in Russia and Kazakhstan. He earned his medical degree in Russia in 1999, and then an MPH at Boston University in 2004. Here he discusses the MDR-TB program.
Why is MDR-TB such a problem in Russia?
The social situation in much of Russia lends itself to the development of TB and MDR-TB. Many patients that we treat in Russia are unemployed and homeless, and many of them suffer from alcoholism and HIV. In addition, high levels of imprisonment in Russia lead to the dissemination of TB and MDR-TB acquired in prisons to the civilian population. It is well known that imprisonment is one of the highest risk factors for TB, and if treatment was not provided in prison, resistance may be amplified, and these patients will develop drug-resistant TB.
MDR-TB is a subset of regular TB that takes least 2 years to treat successfully. Patients usually need four second-line drugs at a minimum, and many patients need five or six drugs.
How and why did PIH get involved in Russia?
There was no protocol anywhere in the world for how to treat MDR-TB. PIH developed a protocol in Peru in 1994, and then they built on the success of that protocol in Russia. Members of the PIH team approached the Russian Minister of Health for permission to start a program because of the number of people at risk there. We set up the program in Tomsk because there was already a program in place to treat regular TB, and we expanded it to include MDR-TB. We have received funding from several sources, including the Open Society Institute and the Eli Lilly & Co. Foundation.
In 2004, we worked with the Tomsk TB Services to apply for a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Upon receiving the funds, PIH was asked to become the principal recipient-manager of the grant, and it has supported our training and treatment efforts in addition to treatment of 950 MDR-TB patients in both civilian and prison sectors. This year’s grant from USAID allows us to expand our collaboration with Russian medical facilities in five different regions.
What is unique about providing treatment for MDR-TB in Russia?
We have to provide treatment through our local partners, because PIH-Russia would need a medical license to treat patients in Russia. So we don’t directly treat patients, but we provide technical assistance and training to the doctors in Tomsk about how to treat them. A patient with lab-confirmed MDR-TB is enrolled into the program and reviewed by a clinical committee. A PIH staff physician is always present at the committee to provide advice. Each patient gets a personalized work-up and a prescription for medications. The committee decides on the regimen and where to start treatment. If the patient lives far from a city, he or she can stay in the larger city TB hospital for the first few months of treatment and then switch to a local facility. About 80% of the patients stay in the hospital for intensive treatment for 3-4 months and up to 6 months, especially if they come from a rural area. In a city, there might be several outpatient facilities. For example, we have TB dispensary offices in Tomsk where patients can come every day, and also a day care hospital, where 160 patients are treated daily without staying overnight.