TURKMENISTAN: FIGHTING TUBERCULOSIS IN THE ISOLATED

UNCLAS SECTION 01 OF 03 ASHGABAT 000629 SIPDIS SENSITIVE STATE FOR SCA/CEN, EUR/ACE, F, OES/IHB AID/W FOR EE/EA E.O. 12958: N/A TAGS: PGOV PREL EAID EINV TBIO SOCI KZ SUBJECT: TURKMENISTAN: FIGHTING TUBERCULOSIS IN THE ISOLATED COUNTRY IS AN UPHILL BATTLE ¶1. (U) Sensitive but unclassified. Not for public Internet. ¶2. (SBU) SUMMARY: Recently thought of as a disease of the turn of the last century, tuberculosis (TB) has once again reared its ugly head. While, in modern times, TB is mostly associated with HIV infection in developing countries, in the former Soviet republics of Central Asia, TB is a disease to be reckoned with in its own right. The collapse of the Soviet Union and its complex health system has helped to create this new epidemic. And, a deadlier form of the disease -- drug-resistant TB -- has emerged, and poses an increasing threat to the region. Turkmenistan, which has isolated itself since independence in 1991, is at further risk, as the government continues to refuse to publicize accurate health data (including the existence of HIV in Turkmenistan). END SUMMARY TUBERCULOSIS IN TURKMENISTAN ¶3. (SBU) Turkmenistan's TB epidemic, compounded by a hidden HIV threat, could cast a long shadow over Turkmenistan's future. TB presents a major challenge to the country's healthcare system and to its economic development via decreased workforce productivity. In line with its erstwhile Soviet neighbors, Turkmenistan suffers from one of the world's highest recorded rates of TB. According to the World Health Organization's (WHO) latest figures, 68 per 100,000 Turkmenistanis have TB, as opposed to six per 100,000 in the United States. In terms of annual TB incidence, Turkmenistan ranks ninth highest in the WHO's "European" region, which comprises 53 countries. DRUG-RESISTANT TB: AN EMERGING, DEADLIER THREAT ¶4. (SBU) Further exacerbating the epidemic is the emergence of "multi-drug-resistant" (MDR) TB: TB that is resistant to at least one of the "first line" -- or standard antibiotics -- used to treat TB. Until this year, the only available data regarding drug resistance in Turkmenistan was from a small survey conducted in 1999 that reported four percent of newly-diagnosed TB cases were drug resistant, and 18 percent of TB patients who had relapsed -- otherwise referred to as "chronic" TB cases -- had a drug-resistant form of TB. However, this year, new data has come to light. In a study carried out by the Government of Turkmenistan of 243 TB patients in the Ashgabat TB hospital, 21 percent of new TB cases were identified as drug-resistant cases, and 34 percent of chronic cases had drug-resistant TB. Therefore, over one quarter of all TB cases had MDR TB: a frightening statistic if it were to represent the national situation. CHALLENGES IN TREATMENT EXACERBATED BY DRUG RESISTANCE ¶5. (SBU) Factors that contribute to the spread of MDR TB include incorrect prescription for treatment, incomplete treatment caused by interruptions in drug supply or poor adherence to grueling treatment protocols, and poor infection control in TB and penitentiary facilities. ¶6. (SBU) When TB is responsive to first-line drugs, patients face treatment regimens lasting between six and 12 months with a standard course of antibiotics that are affordable ($40 per patient) and readily available. However, to cure drug resistant TB, the patient must undergo two years of treatment with a more complex regimen of drugs that are much more expensive than first-line TB drugs. The treatment regimen for MDR TB can be debilitating -- not just due to the duration of treatment, but also to the side effects caused by the more sophisticated antibiotics. Further, all who are infected by a drug-resistant TB carrier also acquire a resistant form of the infection. WHO IS AT RISK? ¶7. (SBU) Populations most at risk of becoming infected with TB or MDR TB in Turkmenistan are all who come into regular contact with those who are infected: prisoners, penitentiary workers, health providers, families of those with active TB, injecting drug users, ASHGABAT 00000629 002 OF 003 and people living with HIV. ...BUT HIV DOES NOT OFFICIALLY EXIST IN TURKMENISTAN ¶8. (SBU) TB is the leading cause of death among HIV patients worldwide. However, while Turkmenistan does have a National AIDS Center in its capital and supports HIV "prevention centers" nationwide, the government refuses to publicize HIV data, and instead insists that HIV does not exist in Turkmenistan. ¶9. (SBU) Shortly after HIV became a pandemic, in 1991, the administration of then-President Saparmurat Niyazov created an HIV/AIDS system under its Ministry of Health. However, President Niyazov was informed that HIV was spread by prostitution and men who have sex with men, acts which are illegal in Turkmenistan. Some feel that admission of HIV prevalence would have therefore promoted Niyazov's perception that his government was not able to enforce certain laws. ¶10. (SBU) Niyazov died in December 2006, and was succeeded by the Minister of Healthcare and Medical Industry, Gurbanguly Berdimuhamedov, in February 2007. While President Berdimuhamedov has continued to welcome international assistance for Turkmenistan's health system, the government has yet to publicly recognize that any of its citizens are infected with HIV. VERTICAL STRUCTURES OF CARE: A VESTIGE OF THE SOVIET ERA ¶11. (SBU) A legacy of Soviet times, Turkmenistan's healthcare system relies on many "vertical structures" -- that is, highly independent, stand-alone systems charged with diagnosing and treating specific diseases or conditions. The TB, HIV/AIDS, and primary healthcare systems are typical vertical structures, each operating separate databases and using different protocols that allow for little interaction or collaboration with one other. These vertical structures, coupled with the country's insistence that HIV does not exist, present a major obstacle for TB patients in need of HIV diagnosis, counselling, and treatment, and vice-versa for those infected with HIV. ¶12. (SBU) The penitentiary system, which falls under the Ministry of Internal Affairs, has yet another vertical healthcare structure that is not connected to the civil healthcare system, presenting problems for newly-released prisoners. And, similar to other countries in the region, TB is an acute problem in prisons. The World Health Organization estimates that TB prevalence in Turkmenistan prisons is 65 times higher than the national level. TURKMENISTAN'S RESPONSE ¶13. (SBU) In 1999, Turkmenistan adopted the "DOTS" strategy, the internationally-recognized approach to controlling TB. Eight years later, Turkmenistan reported 100% DOTS coverage in the civilian healthcare system, and the penitentiary healthcare system began implementing DOTS in June 2008. This "success" is deceptive as the quality of DOTS implementation is questionable. Officially reported data yield good detection rates and treatment-success rates, although the recent drug resistance survey in the Ashgabat TB hospital tells a different story. Although the Government has drafted a number of TB-control decrees (e.g. the 2005-2009 National TB Control Program Plan, and the 2008-2015 National Strategy to Prevent and Control TB),there remains a dearth of specialists who can interpret and analyze data, conduct operational research, test interventions, design evidence-based action plans, and monitor impact. ¶14. (SBU) Turkmenistan publicly reports that none of its TB treatment facilities are administering MDR TB treatment. However, despite shortages of trained TB specialists and inadequate technical capacity to treat MDR TB, the Government of Turkmenistan has purchased MDR TB drugs and began treating MDR TB patients in the Ashgabat TB hospital in January 2009. To guard against resistance to MDR TB drugs, it is imperative to ensure that TB medical staff ASHGABAT 00000629 003 OF 003 are well-trained to diagnose and monitor treatment and that adherence during the two-year regimen is strictly followed. Otherwise, Turkmenistan risks becoming an epicenter of extensively-drug-resistant TB, for which there is no known cure. ¶15. (SBU) In concert with the WHO and Doctors without Borders, which have operated in Turkmenistan since 1999, the U.S. Government -- through USAID -- has responded by providing support to Turkmenistan's national TB program since 2000. Activities have focused on: providing training to improve diagnosis and treatment for those infected with TB; upgrading laboratories with modern equipment to better detect TB; securing WHO-approved first-line drugs to treat "normal" TB; and, developing and publishing a new TB textbook to be used in Turkmenistan's medical education system. THE WAY FORWARD ¶16. (SBU) Some efforts have demonstrated progress in the fight to control TB, such as updating laboratories' equipment and enhancing their capacity to correctly diagnose the infection. However, given the high rate of TB, the emergence of MDR TB, and an unknown prevalence of TB/HIV co-infection, it is clear that much more needs to be done to prevent the further spread of TB in Turkmenistan. ¶17. (SBU) Under the leadership of President Berdimuhamedov, Turkmenistan is showing signs of slowly-but-surely opening up to the wider world. In 2008, Turkmenistan put forth an application for TB funding from the Global Fund to Fight AIDS, TB & Malaria, which was not approved. However, the country intends to submit an improved application, valued at $17.3 million over five years, to the Global Fund's Ninth Round by June 1, 2009. Should Turkmenistan's application be approved, it will provide an incentive for authorities to further open the door to the international arena, which will afford Turkmenistan's health systems greater access to international standards and arm it with the tools to mitigate the growing threat of TB. MILES 1