together4AMR#2 Synergies in Action Strengthening the Fight Against AMR

The podcast series interviews global health leaders who discuss the synergies between disease-specific programs and antimicrobial resistance (AMR). Disease-specific programs have experience in population-based and public health approaches, delivery, and scaling up. There is a need to learn from these programs to strengthen the overall response to combat AMR. The key areas of synergy include awareness and community engagement, good clinical diagnosis, integrated laboratory systems, prevention of infection, and proper drug supply management. The HIV program provides lessons on treatment literacy, adherence, patient education, and surveillance that can be applied to reduce AMR. My name is Anwar Parvez Syed and I welcome you to this series of podcasts together for AMR. In this podcast series, we interviewed five global health leaders who have dedicated their professional careers to combating communicable diseases and antimicrobial resistance. Also they are affiliated with esteemed organizations such as WHO, CDC and World Bank. The views they share in these interviews are personal and based on their extensive work experiences and they do not reflect the official positions of their organizations. This is the second episode of the series and in this episode, we asked our panel members what synergies do you see amongst disease-specific vertical programs that could be used to strengthen the overall response to combat AMR? And here is what they said. Programs to address AMR are really relatively new. The disease-specific programs have been at it for decades. I started my career in TB in the 90s and I think we in AMR in terms of our preparedness and our programmatic approach are perhaps sort of somewhere where TB was in the 90s, in the early 90s. And one of the key strengths of the disease-specific programs is that they do have a population-based and public health approach. And very often the focus on addressing antimicrobial resistance at the moment is on the individual patient, what's going on in the intensive care unit and the management of a patient with complex resistance. And we really need to learn from the disease-specific program, absolutely embed that programmatic public health approach that deals with the whole of the health system and the way that antibiotics are used and abused. I think the disease-specific programs also have an enormous experience in delivery and in going to scale. And a lot of capacity has been built in those program managers in these aspects. And so learning from them, working with them on the AMR approach is going to be really important. Now, when we talk about addressing AMR, we can make it very complicated, we're talking about lots of different specific bugs and drugs and everything else. But what we really need to do is to strengthen systems to prevent, diagnose and manage infection and shift away from antibiotics just being used as a substitute for good hygiene, as a substitute for taking a proper history and diagnosis and as a substitute for good, careful stewardship and management. Now, of course, there are differences between the disease-specific programs and AMR. In disease-specific programs, we're talking about one bug or a few bugs, a very limited range of drugs. And whereas in addressing AMR, we have a very wide range of microbes and drugs and basically antibiotics in particular have been effectively underpinning health system and health service delivery. And so there are very substantial differences. But so perhaps you asked me about where the synergies are. And I think one of the key things is just in awareness and community engagement. Some of these disease programs have worked very well with communities in communicating complex messages simply because we have to change the way that policy makers and society and clinicians think about antibiotics. Antibiotics are really used, you know, sweets almost. They are bought over the counter, very, very widely used for almost all conditions. So learning from and working with disease programs on awareness, the importance of resistance and the importance of good stewardship is going to be really important. We also then need to think about diagnosis. And first of all, the importance of making a good clinical diagnosis. And this is where there are huge benefits because actually, if a patient presents with fever or with a cough, the clinician should have an index of suspicion as could this be TB. In HIV prevalent areas, is this on the differential diagnosis? Could this be malaria? And what you need is a clinician who has a good syndromic approach, who thinks about what the diagnosis is likely to be. Is this something else? Is this bacterial or is it viral? And of course, if it's viral or something, then antibiotics are not indicated. And if it is bacterial, then what's the differential diagnosis? What's the pattern likely? So you get the right drug at the right time and the right dosage. WHO has brought out this Syndromic Management of Common Infections in both hospitals and in primary care called the WHO Antibiotics Book. And that is going to be, that's really helpful. And if that was used widely, not only would it improve clinical outcomes, decrease the inappropriate use of antibiotics, but it's also more likely to help patients to get onto that pathway for the disease specific programmes. Laboratory diagnosis is really important. I mean, I've worked quite a lot in Africa and I've been very impressed to see separate labs for separate diseases funded by separate donors. And of course, that's really unsustainable, massively inefficient, massively difficult for microbiologists. So in addition to having good clinical diagnosis, we need good laboratory systems and systems that have an integrated approach to specimen transfer, information flows, to procurement, to quality assurance, to human resource management and lab development. And it's much, much more efficient if we can do this in an integrated way. And it's much more efficient to have an integrated laboratory system so that disease that happens to be in fashion can cross-subsidise occasionally as those things come and go. Bacteriology is very often the poor relation in all of this. Huge amounts go into virology and other pathogens. But it's really important with the growing threshold of antimicrobial resistance that we strengthen our bacteriology systems so that they can deal appropriately with AMR. Key areas of synergies are preventing infection and just that really good focus, excellent IPC and hygiene, thinking about preventing the spread of pathogens. And then finally, of course, we've got to think about treatment and the drug supply. And again, one of the depressing things one sees quite a lot in emerging countries is wonderful medical stores with superb stock management for TB and HIV drugs and sometimes malaria. And then next door, a ramshackle building where none of those lessons are there and it's a mess with huge problems with stock-out, stock management, quality and everything else. So it would be far too expensive to have antibiotics delivered by the main programme, but actually that skill and expertise in stock management, ordering and supply would be really, really helpful in ensuring that we do have good access to those essential medicines and the right drugs in the right parts of the health system. I think those probably are the key areas, there may be others in different contexts where the synergies are most likely to be. There has been a lot of focus on synergies, integration, coordination, working together as a team with one cause, particularly when we talk of improving health of the people as part of GPW-30. Going ahead, and we have a historical collaboration with TB, antimicrobial resistance initially has not been part of this initiative, but of late in WHO, we have AMR as part of our discussion in all our other programmes also. Why it is so? Because we know that in most of the countries, particularly when I say Southeast Asia, there is a very loosely regulated access to antimicrobials, there is poor awareness, there is widespread irrational prescribing, self-medication, there is abundance of good quality, but also substandard quality and counterfeit medications. There are varying approaches of treating doctors due to anxiety of missing a bacterial infection or covering for a secondary bacterial infection, and this was actually very widespread during COVID. People in healthcare setting also used to use number of antibiotics, particularly when people were in intensive care unit, health emergencies, and the use of antibiotics increased further. There is a perception of, for these antimicrobial agents to be kind of magic bullets, which they are, but if they are not properly used, they can lead to AMR and that leads to a lot of problems. There are certain perceptions, like a perceived demand, expectations from patients also which add to these challenges. All these factors which I have mentioned, they are combined with the high prevalence of infectious diseases and weak healthcare system, they drive the antimicrobial resistance. Vertical programmes, particularly when HIV programme, resistance was a major concern, though it was a vertical programme, but we laid a lot of focus on resistance right from the beginning, and we focused on a lot on treatment literacy, counselling, patient preparedness, not starting treatment before adequate preparedness and counselling has been certified. Treatment literacy, tracking of patients who are lost to follow-up, so that they do not develop resistance, pill count, tracking of lost to follow-up patients, these were certain measures which were adopted by the programme. Of course, a vertical programme, but they were adopted to prevent resistance to antiretrovirals over time. In fact, these lessons which have been learned from HIV programme in terms of treatment literacy, adherence, patient education, counselling, need to be actually utilised for reducing the antimicrobial resistance also. That is where the learning from the HIV programme comes into place. In terms of emergence of resistance, HIV programme, we have a programme of surveillance for antiretroviral resistance, where you do a central surveillance at selected sites and see what is the pre-treatment resistance and what is the acquired drug resistance. So these are some of the things which were actually done exclusively in HIV programme, but can be extrapolated to other microbial agents also. In terms of actual determination of resistance, in HIV programme we used to do basically resistance testing by genotypic resistance testing and you know that similar resistance testing kind of is done by NTV programme also, particularly with MPC using the GeneXpert. So we have some examples where we have used that mechanism, nucleic acid testing or genotypic resistance testing in HIV NTV programme and I am pretty sure that this can be extrapolated to certain other infections, particularly like when I say gonorrhea, resistance to gonorrhea treatment is to the tune of 50 to 60 percent. So these are some of the examples which can be used and we have the platforms which can be now be a multiplex diagnostic platforms for diagnosis on the same GeneXpert machine and R2-NET machine. We can do viral load, we can do TB testing, we can do gonorrhea, pneumonia, hepatitis B, hepatitis C. So these are diagnostics. Similarly, we can develop multi-diagnostic platforms where we can do the resistance testing also not only for HIV TB but for antimicrobials. Another lesson basically which we have learnt in terms of medication is basically proper selection of the drugs, optimal selection and in our HIV programme when Stavodin was there and people were having side effects with Stavodin, the adherence used to be low and we changed the regimen to azithrobutyl-based regimen or tenofovir-based regimen. So drug selection becomes very important in antimicrobial resistance also. The dosing, the route of administration sometime, duration of administration, these are some of the critical elements that we have seen from HIV programme and TB programme which can be actually used for, lessons can be used for antimicrobial resistance programme. So that is brief how we can really utilise our experience from HIV or TB programme and bring these synergies into the programme utilising the same multiplex platforms. We need to strengthen our health system as such. When we go for vertical programme, we are able to actually do infection prevention for that particular area. We put up masks at ART centre, cough hygiene, other things we tell them and how infection prevention control came into focus in COVID-19. So these are some of the areas where we can have, actually not only harmonise guidelines, we can share the resources also. When I say resources, it could be the financial resources, it could be educational resources, human resources. So we can really harmonise and synergise these among disease specific programmes to combat AMR. So we have to move away from these particular areas when I say guidelines, resources, laboratory testing. These are the areas where we can do synergies and prevent AMR to a large extent. Over the period of time, we have seen that there have been some efforts in trying to bring in synergy between the programmes and particularly we know about the drug resistance that have emerged in the tuberculosis, in malaria, HIV, these three programmes classically we know of having a really strong component for resistance. But then we also know that between the programmes, in the early days there have never been much of a synergy because of the real vertical nature of the programmes, because we have vertical programme staff structure, programme management structure, which actually created some issues in really bringing in horizontal synergies between the programmes. But I think there is a lot of ways in which we can really bring in synergies. One of the common things that we have across all these programmes, being infectious disease programmes, is the laboratory component. Lab diagnosis is very much part of all these disease control programmes. The public health laboratory component, which is very vital in strengthening the communicable disease response. There is a lot of opportunity for bringing a lot of synergy between these programmes because, for example, there can be cross-learning and cross-collaboration between the staff in the laboratory space. There can be integrated lab services, which happens quite a lot between, at least between, you know, we have seen examples in between HIV and tuberculosis because there have been cross-referrals and cross-testing, which was really a requirement per se, which actually created that demand for that synergy. But in some of the other diseases where there's really, there will be a lot of benefits, we are not seeing that, probably because there's a lack of understanding from the programme perspective, like what's the importance of resistance and management of resistance and prevention of resistance in some of these diseases. I think that's an area which is still largely unexplored. And the microbials are usually used as a substitute for a good infection prevention control programme or a good primary care programme or a good vaccination programme. So we essentially need to understand this gap. And if we can have, for example, if we have a good IPC programme, you know, it's beneficial to all the health programmes, the communicable disease programmes, and also it is very much helpful for prevention of antimicrobial resistance, the spread of antimicrobial resistance. And we know that, for example, if we have very good infection prevention practices within hospitals treating some particular infections, it will be helpful not only to prevent the infection of the particular infection that we are talking about, but it is also helpful for prevention of transmission of other infections within the hospitals. Then another area is, you know, antimicrobial consumption. You know, there are a lot of studies which have shown that, you know, antimicrobial consumption is driven largely by difficulties in diagnosis and, you know, ruling out other diseases. For example, we know that if we have an effective laboratory system, you know, which can help with diagnosis and ruling out diseases which require antimicrobial use, then we can reduce the use of antimicrobial consumption. And antimicrobial consumption, as we know, is the most important factor which drives the antimicrobial resistance. So if we have opportunities to reduce the use of antibiotics, particularly, we can reduce the antimicrobial resistance linked to a use of antibiotics. But we have very strong evidence from several countries that, for example, vaccination for typhoid, vaccination for pneumococcal infections, influenza, rotavirus, all these, you know, can actually reduce the use of antibiotics, can reduce the prevalence or incidence of infection, which all can, you know, help us to reduce antimicrobial resistance as well. So it can be either by actual reduction of the burden of bacterial infections, then it automatically reduces the use of antibiotics, which actually reduces the chance for resistance. Then if it's viral infections that we are preventing through certain vaccines, again, we know that, you know, antibiotics are misused very much for viral infections globally. So when we try to reduce the incidence of viral infections through effective vaccines, effectively, you are reducing the use of antibiotics, which means you are reducing the risk of antimicrobial resistance emerging. Another area which I felt there's a lot of scope for collaborative work is integrated surveillance. You know, and that requires a primary health care approach, integrated primary health care approach, a primary health care based approach, where, you know, as I mentioned in the beginning, the integrated lab services, similar to the lab services, the integrated surveillance, you know, even without laboratory services, can really help to bring in synergy between different programs and the AMR. Any program, if it wants to be successful, any health program, have a strong awareness generation for the public, HIV, TB, and malaria programs. Programs are vertical programs, instead of doing it like only for HIV, so the same machinery can be synergized and it could be used for, you know, educating the public and creating awareness about the public, which, you know, which could be a villager or a person living in a city or a college student or a school student. So this program has a lot of experience, so use those experiences for generating awareness towards AMR. There is a lot of materials already available regarding these diseases, but still, you know, if you ask the general public about what is AMR, how does it spread, like why you shouldn't be taking the work over-the-counter medication, like many people don't, so why they shouldn't be doing that. The second thing is integrated disease surveillance program. You don't have to duplicate the effect, you know, like this program will collect separate data, that program will collect separate data, so this will add on the budget, this will add on the human resource cost, it will add on the training cost, like a lot of things. So maybe if you can synergize and collaborate on surveillance data collection and analysis by integrating AMR surveillance with the existing systems for HIV, TB, and malaria, it can provide a comprehensive picture of, like, you know, resistance patterns. Now we are talking of more of bacterial drug resistance which is emerging, fungal drug resistance which is coming up, the number of persons getting affected are much more than the population of HIV, TB, and malaria together, right, but still we can draw a lot of examples and we can synergize and collaborate and have integrated surveillance systems. The third thing, you know, in the research initiative, so a lot of funding has been provided to vertical programs and also for AMR. Combined efforts in research and development, for example, studying common pathways for resistance across diseases could help us to get some innovative solutions. It need not be always, you know, laboratory research, it can be a translation, it could be a behavioral science research, and it could be operational, like whatever, you know, but combining efforts in research and development, it is cost-effective and it will be beneficial. Fourth thing I want to emphasize is, you know, training healthcare workers, like, you know, so training healthcare professionals to address both AMR and, like, you know, bacterial, fungal or whatever, or parasites, and for specific diseases like HIV, TB, and malaria or other NCDs. So, this cross-disciplinary knowledge enhances overall patient care. If you go to a district hospital or a medical college, HIV lab will be functioning separately. Even within HIV lab, the ICTC will be separately functioning, ART centers, CD4 laboratory, like, now they are integrated in a way, but there are a lot of silos within a program. But now, if you take, you know, malaria lab will be completely separate, STI lab will be completely separate. The human resources may not be optimally utilized, like, some places they are overworked, some places they are, like, you know, not having adequate work. So, if you have cross-training of healthcare workforces to detect AMR, like, for all, again, you have to build lab capacity and integrated lab systems have to be built, like, all those things are necessary. But, again, training the human resources would be very crucial, and training them in all this. They will be trained on multidrug-resistant TB detection and also for bacterial detection, because, like, if the resources are available, they have the knowledge of doing the testing. Most of the platforms are same. They have, in bacteriology, mainly bacterial culture and IDST, the process might be a little bit different from micro-bacterial testing, but, again, like, if you take the molecular level diagnosis, PCR is done, like, for cross-treating, like, across all the things, right? Like, so, for HAV also, PCR is being done, for TBP also, PCR is being done to find many of the targeted resistant genes in bacterial genomes, like, for example, carbapenemases and things like that. PCR is being done in many of the facilities. So, educating more human resources, like, collaboratively and using them for synergizing the efforts for AMR across all the sectors. So, that would be, like, you know, really helpful. Like, I feel we should start exploring these options and we should try to synergize so that resources are optimally utilized. Let us take the ART program. You detect TB and now you have to start the treatment. So, your treatment protocols are very clear. Drug 1 or drug 1 and 2, as a fixed-dose combination, will be provided to that particular patient and this will be for, you know, given uniformly across them. Now, the regimens are very limited and even when we had multiple regimens, like, it was not more than, you know, maximum 10 or, like, 12 regimens we could have had over the 10 years. Like, you know, multiple regimens were there, no? So, there are so many antibiotics, so many classes and also there are many subclasses and combinations and adjuvants. So, we use a lot of antibiotics in HAV care for treating opportunistic infections and a lot of prophylactic antibiotics are also being provided. If you have very clear treatment guidelines, adequate coverage on when and how a prophylactic therapy or preventive therapy to be provided, like in TB, you have a isoniazid preventive therapy. So, now when you have a very clear guidelines and this program have really proved by adhering to a particular drug combination, you can delay the drug resistance or you can prevent emergence of drug resistance. But the advantage of vertical programs which we are talking about is, yes, like, there is still that drug resistance, but the problem is much bigger with antibiotic resistance because, like, we have so many pathogens to counter, right? Like, there are so many bacteria which could develop drug resistance and there are various mechanisms of drug resistance. If you have a antibiotic stewardship model, will it work? Definitely, you know, like, it will work. Like, if you implement AMS through HAV program and if you really educate the clinicians for starting the prophylactic therapy with the right drug for the right patient, with the right dose for the right duration, definitely, it will have a positive effect on preventing AMR from the HAV sector. Same thing will happen with TB, same thing could happen with any of the NTD program. All the successes from this vertical program which is a low-hanging fruit, which could be implemented very easily, they have a dedicated workforce and if those things could be translated into general internal medicine-related illness, like, you know, definitely, all the facilities are located within the health facility and successes from this program of AMS could be communicated throughout the facilities, health facility and you can scale it horizontally within the health facility. With vertical programs, the advantage is things get implemented in a systematic way, but it's not telling, you know, we should have vertical programs for everything, but if you synergize all this effort, AMS program could be easily implemented across all health facilities. Start with vertical programs and then, you know, expand it horizontally across the board and same thing is applicable not only for AMS, even for infection prevention control, you know, like, if you already have systems in place, so you start with the small program, just, you know, it will have a ripple effect on the whole health facility over time. When we talk about synergies, what we also have to associate that is with the current vertical programs that we run and if you look at AMR, antimicrobial resistance, we just have to go a bit beyond the antibacterial also, even considering antibacterial, but also go beyond the protein antibiotic sensitivity and resistance, which generally people talk about as a part of AMR. So, essentially, what has happened is programs like HIV, this does look at some of the resistance patterns for viral to antivirals and a very structured way in which the program approaches more in terms of viral load testing and ensuring that, you know, the viral load or the CP4 counts are not appropriate, they change the regimens. So, they're looking at it and they're modifying the treatment part of it. Same thing comes with the TB and same thing has also started happening with the malaria program. However, this has not percolated for the overall antibiotics part of it or even antifungals. I will not come to antifungals right now or antiparasites right now, but probably limit myself to viruses and bacterias at this point in time. The synergies basically are, there are existing systems and processes which are developed with disease specific programs, which can be utilized in the AMR program. However, the AMR program actually becomes a bit more complex when you look at at least addressing the antibacterial resistance, becomes a bit more complex because it is not one specific indication like HIV or TB, but it becomes a series of infections and series of typology of patients they have to be dealing with along with the various symptomatology, which is one. So, one of the key synergic elements that I see is having something related to diagnostics. You have a very good diagnostics through cDNA testing in TB for resistance and you're also having testing for viral loads, which is a quasi indicator for resistance and CD4 testing. We have not been able to have that sort of movement towards identifying and diagnosing the resistance and sensitivity patterns. There is a lot of, one, I would say lack of enthusiasm from the clinicians because the diagnosis takes a lot of time. Two, there is also a pressure in terms of their clinical competency and clinical care that they need to provide to the patients, because of which in the overall AMR, this has not been able to play out, which we can actually try to move it from the TB and HIV program, saying that whenever you have certain infectious cases and you have sort of differential diagnosis, you at least go for some type of testing, culture sensitivity testing and try to sort of base it on evidence rather than empirical treatment. If the evidence generation is becoming late, then you can also look at the antibiograms and try to have an empirical treatment for that. The second synergy is in the way that the data systems are maintained, because in TB and even in HIV, there are very specific data systems which are maintained. There is longitudinal record of each individual is maintained and that record is basically followed up and there are certain markers on which the clinicians can take decisions. That is completely lacking or that's basically lacking a bit, because on the EMR front of the medical records, especially on the routine antibiotic usage, this again has the implications because they don't ask for the test or they get the test results late or they don't do a lot of antibiograms or AMR surveillance. So they don't sort of look at that or even looking at the simple antibiotic use itself. So synergy-wise, data systems are the second synergy that I can think of. The third thing that I can think of is the overall commitment and leadership to push this. Both HIV and TB have been able to successfully implement to an extent for the reason because there was a larger political commitment which percolated down for leadership commitment at the state level and further down at the service delivery level too. Because of the commitment, the commitment translates into actions and actions translate into monitoring, which actually goes back to the leadership commitment to ensure that they are on track. So that is something which is hugely lacking and we can actually learn a lot from that on that side also. Infection prevention and control, I see it as more of a cross-cutting initiative. That should probably be the mainstay or the foundation or a cross-cutting thing for every particular service delivery program itself, which I think AMR, it surely is one of the key strategies to work for the AMR containment. There have been good examples probably from TB on airborne infection control work that has been done in the TB program and also sort of looking at usage of some of the personal protective equipment. In HIV also, that has been, that is, I would say slowly it has come to the IPC part of it, but initially that was actually not helpful, but more damaging because the moment if anybody was HIV, then people used to come out almost with like a hazmat suit at that point in time. They would not want to talk to them. They would not want any procedures on that. So that was negatively there initially in terms of, I would say stigma and also discrimination by the people. But I think as the HIV program was able to move towards reducing those stigma and discrimination, they at least got some level of standard precautions in place and which got imbibed into that. So we can surely look at those synergies. Supply chain is crucial for any program and more so for the AMR because it can actually help you do a lot of things. The learnings that we have from HIV and TB, probably a bit more restrictive for the reason that the options available as a part of cocktails of drugs or treatments or therapies is probably fairly limited. But with the routine antimicrobial use, options increase in terms of what is there available. And many a times supply chains do play a role. Many a times it's the supply that is driving the prescription. In HIV program and sometimes to an extent the TB program also got pushed by the supply driven prescription. Similar thing is also probably happening even in the antibiotic usage. The way the supply chain actually works, it works on the first measure that is the cost. The moment it is the procurement, any government will look at the cost part of it rather than the benefit part of it. The cost is the first criteria for procurement. And the moment the cost comes into the picture, the options of certain antibiotics and antimicrobials increases and certain become restrictive. This basically drives the prescription which in turn drives the resistance patterns. So the supply chain which probably to an extent has worked in HIV that based on the evidence coming in, they actually change the typology of drugs that they procure as a part of the overall program and change the regimens or the standard treatment guidelines as they moved on based on the evidence. But that has not happened on the routine antibiotic use or antimicrobial use. It has also happened in TB to an extent but not in the routine thing because one major lacuna is the standard treatment guidelines which are not updated very frequently and they are not many times that doesn't get fed with some of the key sensitivity and resistance patterns. And another thing is that most of the sensitivity and resistance pattern always are coming from hospital settings, not community settings. I think one of the key principles that supply chains can help is to have a very dynamic supply chain process which moves along with your overall antibiograms of the locality or particular region. Your supplies have to be titrated based on that and probably through the standard treatment guidelines and antibiograms and AMR surveillance information which the data use part of it is pretty, I would say, minimal or negligible at this point in time. And if we look at stewardship from the supply chain point of view, it's a double-edged sword. So the stewardship backed with data and evidence is a good way to go further but stewardship with commitment but with priorities of cost and other competing priorities actually hinders the program to move further. Let's try to summarize. Synergies amongst disease-specific vertical programs can significantly strengthen the overall response to combat AMR. The programmatic public health approaches used in TB and HIV initiatives can be adapted to AMR, leveraging established capacities in human resources, infrastructure and health delivery. These programs' success in community engagement and awareness can be utilized to educate about AMR and promote antibiotic stewardship. Robust diagnostic and laboratory services from these disease-specific programs can be integrated to enhance AMR diagnostics and management. Established surveillance systems can be expanded to include AMR, providing comprehensive resistance data and effective drug supply management systems can be adapted for antibiotics to ensure proper use and availability, preventing resistance. Training programs that incorporate behavioral science can optimize healthcare delivery and improve compliance with AMR strategies. Infection prevention and control practices from TB and HIV can reduce the spread of resistant infections. And finally, collaborative research and development efforts can drive innovative solutions for AMR by studying common resistance pathways across pathogens. I'm sure that was pretty exciting. Stay tuned for the next podcast in this series about benefits and barriers to the collaborative approach. Thanks for listening.