It's an illusion that we're now controlling TB
With global health funding on the decline, officials are concerned that strains of tuberculosis (TB), including multi-drug resistant tuberculosis (MDR-TB), may go untreated. Stop TB Director Mario Raviglione spoke to IRIN/PlusNews at the International Lung Health Conference in Lille, France, about the threat of drug resistant TB treatment and the precarious TB funding gap.
Question: The HIV and TB communities have been bemoaning the lack of service integration for years - why can't they get together?
Answer: "It's a turf issue. If I am dealing with an issue, then I tend to focus on my issue. If someone comes and disturbs me with some additional work then I would be reluctant. I think it's a human reaction.
"We need to educate people in public health that if you have a person that has TB in the African context, it is likely that this person will be affected by HIV. It makes no sense to have this person come in the morning to a clinic to collect their TB drugs and then tell them to go in the afternoon to another clinic to collect their HIV drugs.”
Q: Directly Observed Treatment Short course (DOTS) has been slammed by some as ineffective and paternalistic - is the World Health Organization (WHO) planning to move away from DOTS?
A: "I'm aware that some people say that it is not right, it's a paternalistic approach... someone actually called it a 'veterinarian approach' to public health, meaning not that patients are animals but that the TB community wants to treat them as if they were and supervise every single thing they do. It makes some sense when you look at it from that perspective.
"Nevertheless, DOTS is an approach that where it worked, has prevented the onset of drug resistance and cured patients. Where it hasn't worked, like in some parts of South Africa, it has allowed incredible epidemics of MDR-TB and even MDR-TB among people living with HIV. [MDR-TB is resistant to one or both of the strongest anti-TB drugs.]
"Our position is not going to change, we will recommend constantly that patients be counselled, supervised in a positive way, reminded on a daily basis and supported throughout the course of this treatment.
"I would be the first one to say, 'I'm educated enough that I don't have to be reminded every day - it's humiliating for me.' But there are others who are not in a lucky position like that and they tend to lose their treatment because simply they are not counselled enough, not supported enough.
"One has to weigh the ideology and the principles against the practicality of things."
Q: What's the biggest issue in TB at present?
A: "Second-line drugs are rare today in the sense that the production of quality drugs is limited to very few WHO prequalified companies... and some are difficult to produce.
"The market is not enough for the industry... to produce the amount of drugs that would be needed if we were able to detect and diagnose all the MDR-TB cases.
"At the moment, there is a vicious circle because in order to have a better market for second-line drugs, we need a higher volume of patients, which is simply not there because most countries do not do systematic drug susceptibility testing. About 90 percent of the MDR-TB cases we think exist are not detected by the system so the market is limited to about 30,000 cases per year that are officially notified.
"By the time we have laboratories capable of diagnosing everyone with MDR-TB, then we will encounter a real problem because there will not be enough drugs to treat these patients, which will become a big, huge ethical issue. I really hope these two things go together, the development of systems to diagnose cases so that the volume of cases detected increases and it becomes more attractive for the industry to produce the drugs.”
Q: A study from Botswana recently showed problematic adherence to isoniazid preventative TB therapy (IPT), which uses one of the two main drugs used to treat TB to prevent active disease. Some have linked this to the drug resistant TB burden in the country - how should we be interpreting this study?
A: "The number-one message I take away from the Botswana study is that it's a challenge to implement large-scale preventative therapy for TB.
“Mathematical models show clearly that if you implement preventative therapy, we will probably be about 7 percent effective in preventing TB. The problem is the feasibility.
"I'm not that concerned, to be honest, with the issue of developing resistance [within IPT provision] because people who are infected with TB and don't have the active disease - there's such a small amount of bacteria in their body that it is quite unlikely that one of them is a mutated [strain] that is resistant from the start to isoniazid, so that I'm not wasting my drug or stimulating resistance.
"However [IPT] will change depending on setting. It's clear that if you have basic resistance to isoniazid in the population and that resistance is already 10-15 percent, then your prophylaxis in 10-15 percent of the cases won't work.
"If I were in the former Soviet Union, where isoniazid resistance is 30 percent, then there is no way on earth that we'd use a prophylaxis with isoniazid because in one-third of patients it won’t work. This is why, in some settings, it might be good to use a combination of drugs.”
Q: What is the future of TB funding?
A: "Funding for TB has gone up quite substantially in the last decade but there is still a gap. In the middle-income countries - Brazil, Russia, India, China and South Africa - 95 percent of TB funding is domestic. On the other hand, if you look at the poorest countries, particularly in Africa, you will find that most rely on international financing for more than 50 percent [of their TB programmes].
"With the decrease in international aid as a consequence of the financial crises... we are in a very fragile situation. The achievements we have witnessed over the past decade are at big risk in the next five years if international financing [and] domestic financing are not consolidated and maintained. If not, we will go back 15 years because TB is like that - it is not a disease that will go away in one or two years, it requires constant investment.
"It's an illusion that we're now controlling TB.”