Fuelled by the HIV pandemic and the spread of drug-resistant strains, tuberculosis (TB) has re-emerged as a major threat to global health. TB is a curable disease that continues to affect millions of people globally each year, and is a leading cause of death in HIV positive people. According to the 2009 WHO Report on Global TB Control, there were 9.4 million new TB cases in 2008, out of which 1.4 million (14%) were HIV positive (78% of them were in Africa and 13% in Southeast Asia). Mortality from TB was 1.7 million, and about 0.5 million of these deaths were in People Living with HIV (PLHIV), who are at a much increased risk of contracting TB. In high burden HIV settings (like the sub Saharan region) more than 70% of TB patients are living with HIV. So, universal access to HIV care cannot be achieved without addressing TB.
To make matters worse, over the last decade, 5 million people developed drug-resistant TB, but less than 1% had access to appropriate treatment, and 1.5 million died. Only 7% of the estimated 440,000 MDR-TB cases in 2008 were reported to the World Health Organization (WHO), and only about 1% of the patients were enrolled under programs to provide internationally quality assured treatment. India is home to 2.5 million people living with HIV and bears one fourth of the estimated global burden of MDR-TB.
Infection with HIV further complicates management of MDR TB, and data from many settings suggest that mortality from MDR TB in HIV infected patients is very high. So MDR TB/HIV is the Perfect Storm and we cannot wait any more to let it pass. In resource limited settings, which carry most of the burden of MDR TB and co infection with HIV, there is insufficient access to quality assured diagnostic capacity, which results in delays of diagnosis and probably in deaths, especially among the PLHIV. HIV infected patients often have sputum negative and extra pulmonary TB which further complicates diagnosis. Limited quality assured drug access, drug-drug interactions, side effects, pill burden, and long treatment duration add to the problem of treatment adherence.
These issues were raised at the recently concluded 10th International Congress on AIDS in Asia and the Pacific (10th ICAAP). One of the meetings, organized by Medicins Sans Frontieres (MSF), focused on the challenges in scaling up Diagnosis and Treatment of Drug Resistant TB in PLHIV. Results of a case study from MSF HIV project in Mumbai, India, treating MDRTB/HIV co-infections were also shared. This study is among the first cohorts of HIV/MDR-TB co-infected patients in India. It was a highly resistant cohort with previous exposure to second line TB drugs, mainly in the private health sector. To date, a cohort of 71 HIV infected patients have been diagnosed with MDR TB, 56 cases were confirmed and 15 were suspected. 59 patients were started on treatment. One of these with susceptible TB was excluded from analysis. Out of the 12 who did not begin treatment, 7 died. Final outcomes (in the 2007 to 2011 cohorts, n=58) were as follows:--13 (22%) were successfully treated, 13 (22%) died, 7 (12%) defaulted, 2 (3%) failed treatment and 23 (40%) are alive in treatment. Thus, overall 20 of the 71 patients died, including the 7 who were not initiated on treatment. All the patients demonstrated significant immunological improvement (increased CD4 counts).
There are many challenges in Scaling up Diagnosis and Treatment of TB in PLHIV, including psycho- social challenges, like the stigma attached to the burden of double disease, need for emotional support to the patient and the family to overcome the severe mental health problems, as well as access to quality assured drugs. As of now, there is:
(i) Limited number of quality sources.
(ii) Limited affordability due to high price of DR-TB treatment--The drugs, for a standard 18-24 month treatment course, currently cost between US$ 4,400 and $9,000 per patient.
(iii) Neglect of children and people living with HIV. Only 2 drugs in pediatric presentation exist and there is risk of over or under-dosing. Interactions between DR-TB and HIV drugs are largely unknown, and the current treatment has severe side effects, pill burden, and long duration treatment length of 18 to 24 months.
(iv) Weak TB advocacy networks(v) Neglect of TB Research and Development. As TB chiefly affects developing countries, there is no lucrative interest for pharmaceutical industry in developing new drugs. Only one new drug is close to reach the market: TMC 207 (by 2012 if accelerated approval).
It is essential to break the vicious circle by improving diagnosis, as improved diagnosis will contribute to increased demand, making the DR-TB drug market more attractive to drug developers and manufacturers. The immediate objective for TB research and development is to improve treatment of MDR-TB by developing alternative, more user-friendly formulations and use of drugs in children and people living with HIV. In the long term there is need to discover a new short regimen to treat both drug-sensitive and drug-resistant TB, compatible with HIV treatment.
According to Javid Syed of Treatment Action Group, "There is poor coordination between HIV and TB programmes, and lack of advocacy services for TB/HIV co infections on part of both—HIV and TB activists. We have to concentrate on the three ‘I’s---Intensified TB case funding, Isoniazid preventive therapy (IPT), and Infection control of TB in congregate settings. Currently, less than 1% of those PLHIV in need are on IPT. We need to scale up collaborative services and increase funding for TB services and research. Instead of pitching one disease against the other, we should expand the pie for all global health needs. If a virus and bacteria can work together, why cannot we?" (CNS)
(The author is the Editor of Citizen News Service (CNS) and reported on-site from 10th ICAAP, Busan, South Korea for CNS. She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. Email: firstname.lastname@example.org, website: http://www.citizen-news.org)