Tackling Infections to Benefit Africa (TIBA) – An Inclusive & Equitable Health Research Partnership

Abstract

Neglected tropical diseases (NTDs) are a group of 20 mainly communicable diseases imposing global health burdens on the world’s poorest communities, similar to AIDS, TB, or malaria. They debilitate, disfigure, kill, and trap people in poverty. NTDs overburden already weak health systems in Africa, and the UN Health SDG 3 cannot be achieved without tackling NTDs. Tackling Infections to Benefit Africa (TIBA) is an Africa-led multidisciplinary research and delivery partnership across 9 NTD-affected countries where 75 million people live in poverty. TIBA aims to improve access to current and new NTD interventions and healthcare for these populations, advancing health equity by engaging with affected communities and local experts to generate context-relevant, evidence-based, scalable, and sustainable interventions to improve health access, clinical care, and healthcare uptake.

Introduction

TIBA established in 2017 with an initial budget of £6.9M. We created an inclusive research model and challenged traditional approaches to generate context-sensitive scientific interventions including prevention, diagnostics, drugs and policy approaches for NTDs, malaria, and emerging pathogens. Our four guiding principles are: Africa-led research and delivery agendas; working in Africa for Africa; inclusivity; and delivery through truly equitable partnerships. We have 20 research partners based in 10 countries: Ghana, Sudan, Rwanda, Uganda, Kenya, Tanzania, Zimbabwe, Botswana and South Africa and the UK, each with significant expertise in disease transmission and control in Africa. Our governance and management processes enable African partner institutions to define the agenda and direction of their research, with African-led peer review ensuring academic excellence and rigor. All 55 TIBA research projects to date are based on local health priorities. The partnership works with 20 core stakeholders across health ministries, development agencies, continental think-tanks, and commercial companies.

Who should benefit?

In our 9 African partner countries, 75 million people living in poverty are at risk from NTDs. NTDs cause devastating health, social, educational, and economic consequences resulting in ~80K annual deaths. NTDs trap people in poverty and degrade the capacity of health systems, limiting their ability to deal with outbreaks and emerging pathogens. To quote the President of Tanzania in 2022: ‘the effects of NTDs … fall disproportionately on women and girls, because high-risk water-contact activities are part of their daily routine, making them more likely to fall ill. When they do, they cannot attend school, go to work, or take care of themselves or their families ... they may also be expected to give up a job or leave school to care for a relative with an NTD.’ TIBA chose to focus on NTDs for 5 reasons: i) NTDs have traditionally received less research and control focus, effectively making them diseases of neglected people; ii) most NTDs are preventable and treatable; iii) NTDs place a significant burden on health systems compromising national and global health security; iv) NTD prevention and control is a proven best-buy for health, akin to childhood vaccination; and v) our individual partners have proven records of delivering health impact in Africa through NTD research. TIBA delivers better and accessible healthcare for individuals and stronger and more resilient national health systems, driving health equity at individual and national levels. 

NTD prevention and control is hindered by several factors, including lack of appropriate interventions tools, lack of effective deployment strategies for currently available tools, and limited health budgets. TIBA targets some of the highest burden NTDs in Africa, including lymphatic filariasis (elephantiasis), schistosomiasis (bilharzia), intestinal worms, and trypanosomiasis (sleeping sickness). We identify infection reservoirs, develop and evaluate diagnostics and treatments, improve clinical care, and identify effective deployment strategies for greater access to diagnosis and treatment. Our research has identified mothers as reservoirs of sleeping sickness responsible for mother-to-child infection in Uganda, developed an algorithm village health workers can use for diagnosing paediatric schistosomiasis in Zimbabwe, and identified strategies for accessing preschool children for schistosome treatment in South Africa, Zimbabwe, Rwanda and Tanzania. These findings now inform national and global policies and guidelines for NTD control, including Zimbabwe’s 2023-2030 NTD Masterplan and WHO’s 2021-2030 NTD Roadmap.

Engagement 

TIBA is locally led in terms of problem identification and prioritization, project development, budget allocation, and research. Our work starts with community visits to assess needs and develop community-led engagement and dissemination plans. We meet affected community members individually to avoid social-cultural selection bias. Then we meet local leaders (chiefs, councilors, school heads), community health workers (CHWs), and local health professionals. Subsequent activities are reviewed at regular community meetings and adjusted in response to community inputs. Our research agenda is informed by Ministries of Health and major international stakeholders to align to national priorities and continent-wide health strategies. Our main international stakeholders are WHO, WHO Regional Office for Africa (WHO AFRO), African Union Development Agency’s New Partnership for Africa’s Development (AUDA-NEPAD), and African Academy of Sciences (AAS). Our advocacy partners are Uniting to Combat Neglected Tropical Diseases and Youth Combating NTDs. 

Engaging with policy makers ensures sustainability and scaling of TIBA’s research findings and training. As a result of TIBA’s paediatric schistosomiasis research, national governments are including treatment of preschool children in their schistosomiasis control programs. WHO now recommend inclusion of preschool children in national NTD control programs in all schistosome-endemic countries in Africa, Asia, and South America. During the COVID-19 pandemic, national governments in Rwanda, Botswana, Ghana, Kenya, and Zimbabwe expanded real-time genome sequencing capabilities introduced by TIBA to build nationwide sequencing capacity for variant surveillance. 

We recognize the importance of key community actors as mediators between researchers, patients and study populations, and local traditional leaders. TIBA works with CHWs in all 9 partner countries for community-level NTD activities. In Zimbabwe, our health awareness programs have led to increased community health-seeking behaviour for schistosomiasis treatment. Through participant engagement within the community, TIBA identified NTD treatment gaps in elderly and chronic NTD sufferers, e.g. elephantiasis patients. TIBA highlighted this need to heads of states attending the 2022 CHOGM Kigali Summit on Malaria and NTDs, contributing to committing financial support for NTD control through the Kigali Declaration on NTDs. TIBA also included these groups in national NTD masterplans – such as Zimbabwe’s 2023-30 masterplan, under preparation – and researched the scale of unmet health needs across NTDs and African countries.

Research

One insight into health research has been the danger of conducting research that does not translate to improved health. To avoid this, TIBA ensures all our work addresses local health needs, can be translated into health benefits to address the health needs, and any gains are sustained and have local buy-in. To achieve this, TIBA’s research and delivery agenda is shaped through responsive engagement with local stakeholders. Every project PI must demonstrate local demand for the research at all stakeholder levels, co-produce the research proposal, deploy an effective pathway and strategy for the research findings. Effective NTD control strategies require data to quantify the problem, identify target populations, evaluate efficacy of interventions, develop effective deployment strategies for interventions, and determine cost-effectiveness. 

There are still huge data gaps to fill. Following TIBA Uganda’s finding that mother-to-child transmission of sleeping sickness is still occurring, the scale and frequency of it needs to be determined. TIBA Uganda now needs to conduct epidemiological studies to generate data to guide the local ministry of health’s policy on prenatal sleeping sickness screening. Similarly, our work in Zimbabwe challenged health inequality in young children. For several decades, children under 5 were excluded from schistosomiasis treatment, creating a significant health inequity. The basis for their exclusion assumed young children did not need treatment and the drug used for treating schistosomiasis would not work effectively in young children. TIBA led scientific studies challenging this, providing the evidence-base used by the WHO to revise the treatment policy to allow treatment for these children. As a result, 50 million more African children are now eligible for schistosomiasis treatment, and for the first time the new WHO 2021-2030 roadmap includes guidance for the inclusion of pre-school children in schistosomiasis treatment. TIBA participated in developing the Phase 3 clinical trial protocol for a child friendly formulation of the schistosomiasis drug (praziquantel) which received validation from the European Medicines Agency in 2022. TIBA has determining strategies for targeting the young children across different African health systems to ensure all children can access schistosomiasis treatment.