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AFRICA: Rethink urged over TB treatment
Science in Africa
January 2005

http://www.scienceinafrica.co.za/2005/january/tb.htm

In the crowded wards of African hospitals, coughs and bony bodies tell the story of a deadly return. Tuberculosis (TB), supposedly defeated 40 years ago, is back, riding on the AIDS epidemic, and the world is ill-prepared, says the relief agency Medecins Sans Frontieres (MSF).

In its study 'Running out of Breath? TB Care in the 21st Century', MSF's Campaign for Access to Essential Medicines urges a radical rethink of the global approach to the disease.

TB kills two million people every year, nearly all in developing countries. Yet TB, if detected early and treated, is curable.

For HIV-positive people, TB is the most frequent opportunistic infection and the leading cause of death. The scale of the problem is dramatic, with some 12 million people co-infected with HIV and TB, two-thirds of whom live in sub-Saharan Africa.

"National TB programmes are not coping with the burden," said Dr Gilles van Cutsem, who runs an AIDS/TB clinic for MSF in the South African Township of Khayelitsha.

The problem is that the global anti-TB strategy - Directly Observed Treatment Short-course (DOTS) - was designed before the full impact of the AIDS epidemic on over-stretched health services was fully appreciated.

Launched by the World Health Organization (WHO) in 1994 and now implemented in 180 countries, DOTS has improved TB detection and treatment compliance, but reaches less than one-third of TB patients worldwide, according to the New York-based Global Alliance for TB Drug Development.

"HIV/AIDS has transformed the landscape of TB care and control," said Dr Francine Matthys, TB advisor for WHO.

DOTS targets active pulmonary TB, the most infectious strain of the disease, but people living with HIV/AIDS are more likely to have latent and extra-pulmonary TB, which the standard diagnostic test fails to pick up. Undetected and untreated, TB is the number one killer of HIV-positive people.

"HIV-positive patients with TB are second-class citizens for national TB programmes," remarked van Cutsem.

Newer tests used in rich countries are more effective in detecting all kinds of TB, but are also more complex and expensive. "What we need is a simple, field-adapted test that delivers reliable results in even the most resource-poor settings," Matthys told IRIN.

TB therapy involves a daily pill for up to eight months, long after symptoms disappear. Because stopping treatment prematurely creates drug resistance - a growing problem worldwide - DOTS was introduced, with a health worker watching the patient take their pills for at least two months, and providing regular monitoring afterwards.

This is labour-intensive and time-consuming for both health workers and patients. It also means that DOTS can only be properly implemented in the most stable settings. DOTS fails, for example, with nomads, migrant workers, refugees and internally displaced people.

DOTS also contradicts the approach of antiretroviral treatment where AIDS patients pop their daily pill on their own and have "treatment buddies" to remind them.

Another problem is that TB services are implemented vertically, isolated from AIDS programmes. "They have different administrations, different buildings, even different loyalties," said Marta Darder, coordinator of the Campaign for Access to Essential Medicines in South Africa.

MSF is experimenting with an alternative approach in its integrated TB/AIDS clinics, like the one run by van Cutsem, where seven out of 10 TB patients are HIV positive.

"We are trying to break the wall between the two services by integrating the teams," said van Cutsem. "It's not an easy process, but it is much better for the patients."

With the integrated services there is one entry point, one monitoring system and one-stop care, instead of the patient having to queue twice in different places, with additional transport and time costs.

Recognising the problem, WHO and the Stop TB Partnership established the TB/HIV Working Group to coordinate the global response to the twin epidemics and strengthen collaboration between TB and AIDS programmes.

"These activities will ensure the survival and improved quality of life of HIV-infected TB patients but are not implemented by many affected countries," said Dr Paul Nunn, coordinator of Stop TB's Unit for TB/HIV and Drug Resistance at WHO's Geneva headquarters.

The basic problems of DOTS, says the MSF study, is that it built on old, tried and tested technologies instead of developing more effective diagnostics, vaccines and drugs. AIDS magnifies the limitation of DOTS - but it also offers an opportunity to rethink the global TB strategy, the report concludes. - [IRIN]

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