AFRICA: Rethink urged over TB treatment
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]
More information:
[This Item may not necessarily reflect the views of the United Nations.
Copyright (©) UN Office for the Coordination of Humanitarian Affairs 2003]
www.irinnews.org
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