Eliminating malaria, tuberculosis & HIV/AIDS in South-East Asia: Why cross-border is so critical

Over the last 20 years, the world has made significant progress in the fight against tuberculosis (TB), malaria and HIV/AIDS. With over 25 per cent reduction in TB deaths, the scale-up of TB diagnostics and treatment has saved more than 60 million lives and averted millions of infections. South East Asia (SEA) Region still has close to half of the disease burden in the world1. Malaria is now on the verge of elimination in many countries of SEA, with the greatest progress in the reduction of malaria burden being made in this region2,3. First reported in 1981, HIV/AIDS epidemic in the Region peaked in the mid-1990s. Currently, the National HIV prevalence levels are very low, at 0.3 per cent in the adult (15-49 yr) group4. AIDS-related deaths in the Region have been reduced by 27 per cent since 20105.

The progress to overcome these global priority health issues has been nothing short of spectacular. Encouraged by this and aligning with the Sustainable Development Goals, all countries have committed themselves to eliminating malaria, TB and HIV by 20306. India announced the target of ending TB by 2025, five years ahead of the rest of the world 7. A major effort is presently underway to achieve these goals amidst global challenges such as the COVID-19 pandemic over the past three years.

Why addressing cross-border issue is so important

Despite these advances and political commitment expressed, many challenges still remain to be addressed in SEA Region including India. Cross-border movement of populations is one of these. For example, most malaria now remains in border areas and countries such as Bhutan, Bangladesh, Nepal, Thailand and Timor Leste, which are near elimination and are not able to achieve malaria elimination due to border malaria8,9. Moreover, the risk of and vulnerability for HIV/AIDS, TB and other communicable diseases are greater in the border area than in the country10–13.

Studies show that HIV prevalence among migrants is generally higher than the adult prevalence in host and source countries. For example, adult HIV prevalence in Thailand was 1.1 per cent but among Cambodian and Burmese migrants working in Thailand was 2.5 and 1.2 per cent, respectively14,15. The migrants not only have higher prevalence of TB and multidrug-resistant (MDR) TB but also face significant challenges and barriers in accessing diagnosis, treatment and prevention services16,17.

It is a wellknown fact that disease pathogens also cross borders and require no passport or visa to do so, thereby leading to disease transmission, jeopardizing global health security18, as well as progress towards eliminating TB and ending the AIDS epidemic by 20306. Today, focussing on cross-border collaboration among countries is therefore critical to address the ‘last mile’.

Clearly, the health systems in border areas are weak, and vulnerable people’s access to prevention and treatment, in general, is inadequate; also, the integration of specific disease prevention services in health and social services is often missing. Disease specific data in cross-border context have not been readily available, with limited sharing of surveillance and epidemiological data between countries, especially for those crossing international borders.

Engagement of vulnerable people at borders remains inadequate due in part to the lack of access to information and education. Often, those crossing borders face stigma and discrimination while trying to access testing and treatment services.

Most importantly, the lack of cross-border coordination and access to service remains a major impediment to regional disease elimination. The countries in SEA agree that no country can achieve elimination in isolation3 and that achievement of national goals/targets of disease elimination by 2030 will not be possible without addressing cross-border issues. Given the limited nature of health services in border districts, the COVID-19 pandemic has further worsened the situation of TB, malaria and HIV/AIDS services.

From programmatic perspectives, addressing cross-border issues is important given the vulnerability of populations migrating across international borders, the need for and imperativeness of surveillance and intercountry notification of cases crossing borders, and for ensuring access to uniform treatment services and achieving treatment adherence, especially for example, for TB which requires at least six month therapy. Inability to detect cases early and prompt initiation of treatment can lead to a chronic condition, prolonged transmission and development of MDR-TB, which is harder and longer to treat successfully.

To overcome these practical challenges and to facilitate inter country collaboration and coordination in cross-border activities, the country coordination mechanisms of the eleven SEA countries have recently established a regional mechanism called South East Asia Regional Coordination Mechanism Forum (SRCMF), based in New Delhi (personal communication). There are many agencies interested in cross-border disease control and SRCMF is working closely both with the countries as well as various partners, including Roll Back Malaria, World Health Organization, Global Fund, Asia Pacific Leaders Malaria Alliance, Stop TB partnership and SAARC Development Fund. Given that SRCMF was established by the member countries themselves through their country coordination mechanisms, each of which is represented on its board, it is better placed to facilitate inter-country collaboration while addressing cross-border issues.

Strategic directions

In the past, the health ministers and concerned programme managers of the SEA countries have expressed their national commitment to collaborate for cross-border control of communicable diseases19,20. Appropriate cross-border action is expected to not only ensure health security in the region but go a long way to achieve malaria, TB and HIV/AIDS endgame by 2030. In a longer time frame, this will also improve the economy of the people, society and the country. Inter-country collaboration at border areas can help also pave the way for combating emerging infections such as COVID-19 by strengthening core capacities for surveillance and response at the ports of entry.

Specifically, to achieve the goal of disease elimination by 2030 (2025 for TB elimination in India), including in border areas, the following actions are suggested:

Firstly, enlisting high-level political commitment at the national, State and border district level for cross-border disease prevention and control as a priority and thereby to mitigate and urgently reverse their impact. Forging a sustained inter-country collaboration for joint and coherent programme planning and implementation will be a crucial and necessary step for coordinated action across the international borders.

Secondly, ensuring that countries having common borders agree and commit to joint activities such as district-to-district cross-border coordination meetings, joint planning and review, synchronized implementation of interventions such as polio immunization, insecticide spray, strengthening of surveillance and monitoring and evaluation (M and E), joint mapping of health facilities and risk assessment to inform response. A uniform treatment regimen and strengthening prevention can be agreed upon among countries, including the establishment of an electronic platform for international medical consultations regarding the management of drug and insecticide resistance, and MDR-TB in the SEA Region.

Thirdly, strengthening surveillance including cross-notification of cases moving across borders and referring a patient promptly for treatment continuation and completion, would lead to interruption of further transmission. Besides, ensuring reporting from the private sector to the Health Management Information System (HMIS) and integration of border M and E indicators into HMIS can strengthen the evidence base for policymaking and public health action. Continuous and seamless sharing of information on surveillance and programme activities through regular coordination meetings or through email, phone, websites, data dashboards as well as through social media such as WhatsApp group is identified as an essential activity.

Fourthly, enhancing the health system capacity at the border districts by improving the capacity of the health functionaries and awareness among the local community leaders on control of cross-border diseases is crucial to achieve the elimination goals. Equally important is boosting and sustaining access to and provision of essential health services such as early case detection and management services, availability of and access to essential diagnostic technologies, life-saving medicines and vaccines in border areas. Education and information services, along with enhanced connectivity along and across borders, will help a great deal in building and strengthening core capacities in disease surveillance and response.

Finally, partnership building with government departments such as health, labour, and customs; civil society; private organizations; and international donor and technical agencies will help strengthen primary health care in border districts in terms of human resources and financial support. Advocacy for increased political attention and mobilization of additional resources would be key in this regard.

Both the Universal Health Coverage and Sustainable Development Goals 2030, to which all countries of the SEA Region are committed to, require that everyone everywhere, including those living in border areas have equitable access to good quality healthcare with the central transformative promise of ‘Leave No One Behind’21. Successful implementation of cross-border activities and a robust health infrastructure, especially staff, is key to achieve these national and regional aspirations and goals relating to disease elimination/eradication.