Bedaquiline is an anti-tuberculosis drug that is still being tested in clinical trials. It is not yet approved anywhere in the world, though it is steadily making progress towards approval in Europe and the United States.[^Janssen2012] Several organisations, including the Treatment Action Campaign, the Treatment Action Group, HIV i-Base, the Global Tuberculosis Community Advisory Board, Medecins Sans Frontieres and the Southern African HIV Clinicians Society have called for the drug to be made available to patients with drug-resistant tuberculosis (TB) before it is approved. This demand was made as far back as the World Lung Conference in Mexico in 2009. Yet little progress towards pre-approval access has been made in South Africa. The South African medicines regulatory authority, the Medicines Control Council (MCC), has responded sceptically. We make the case for pre-approval access in this article. Although we deal with bedaquiline specifically, the arguments made here can perhaps be applied to other drugs, including another new anti-TB drug, delamanid, which is also at an advanced stage in clinical trials. Pre-approval access has also been called compassionate care access and expanded access. We think pre-approval access is the most dispassionate and accurate way to describe what we are calling for. By pre-approval access we mean making bedaquiline available, with reasonable conditions, to patients with drug-resistant TB before the drug is approved. In South Africa the obvious mechanism for doing this would be through Section 21 authorisations approved by the MCC.[^Section21] Patients who immediately need life-saving treatment might also access the drug by taking part in a trial that has been proposed to examine the drug's safety. Pre-approval access has risks. While we have some understanding of bedaquiline's safety and efficacy, there is not yet enough data to say with the utmost confidence that it is safe and effective. Prescribing it to patients with drug-resistant TB is undoubtedly risky. The MCC is understandably cautious about pre-approval access. No phase III clinical trial of bedaquiline has been completed. Although results of a randomised controlled Phase II trial of bedaquiline have been published, the trial was small. Also, there is a clamour for the MCC to register thousands of dubious treatments for numerous ailments even though they have not been tested properly. It is understandable that the MCC is worried that giving pre-approval access to one drug will open the door for other drug-manufacturers to demand pre-approval access.[^Goldacre2012] These are legitimate concerns. Making medicines available to patients before they are properly tested, evaluated and approved is not something that the MCC can do at a whim. Nevertheless, we believe the arguments for making bedaquiline available are compelling and outweigh the concerns. ## The arguments for pre-approval access ### It is reasonable for patients with drug-resistant TB to choose to take experimental medicines Drug-resistant TB treatment outcomes vary a lot from location to location. Nevertheless, the risk of treatment failure and death is high in all settings. In a recent meta-analysis of over 9,000 patients with multi-drug resistant (MDR) TB from 23 countries, 46% died, relapsed, failed treatment or defaulted.[^Ahuja2012] Several studies of drug-resistant TB in South African settings have been published. In a study of a Durban cohort of 60 people with extensively drug resistant (XDR) TB, 25 (42%) died. Only 12 (20%) sputum-converted.[^Odonnell2009] A study of the Tugela Ferry TB register for the years 2007 to 2009 found that at one year, mortality with XDR TB was 82% and with MDR TB it was 69%. Over time MDR TB mortality dropped from 87% to 45%, perhaps reflecting improved treatment, but there was no significant decrease in XDR TB mortality.[^Gandhi2009] In Kwazulu-Natal, health workers are at particularly high risk. A study by Max O'Donnell and colleagues found that the incidence of MDR-TB hospitalization was about 65 per 100,000 health care workers versus 12 per 100,000 for non-health care workers (IRR: 5.46, 95%CI: 4.75-6.28). For XDR TB it was 7 per 100,000 health care workers versus 1 per 100,000 non-health care workers (IRR: 6.69, 95%CI: 4.38-10.20).[^Odonnell2010] The state has a duty to do everything it can for its employees who have likely become ill because of their work. The current standard of care is a great burden for patients. The World Health Organisation (WHO) guidelines recommend a 20 month treatment regimen. Five recommendations are given for composing the regimen. All the recommendations are graded *very low quality evidence* which is the WHO's lowest level of evidence. This grading means, "Any estimate of effect is very uncertain."[^WHO2011] The side-effects of the standard drugs used to compose MDR TB regimens are awful. In one South African MDR TB cohort, more than half the patients taking aminoglycosides became hearing impaired.[^Harris2012] In another, 28% had severe adverse events.[^Odonnell2009] In a Turkish cohort, side effects were severe enough to cause drug changes in more than half the patients.[^Torun2005] This is how an MDR TB patient, Colisile Lushaba, who kept a blog of her progress, described taking her regimen: > I take 10 pills in the morning, together with the injection. In the evenings I only take antiretrovirals. Although I am slightly better than I was at the start of my treatment, I am not yet feeling very well. I am still coughing, though not as much as I used to. I still vomit a lot, especially after taking the pills. I have to say that this treatment is very difficult and, right now, I am still feeling very weak and unsure of where I will be in the next few months.[^Lushaba2011] In a nutshell, patients on MDR TB regimens typically take a side-effect ridden regimen with a poor evidence base for more than a year and a half and still only have a slightly better than half chance of a successful treatment outcome. Mortality and morbidity are extremely high. Given this situation, it is reasonable for patients with drug-resistant TB to consider taking experimental medicines that have some good quality safety and efficacy evidence. Below, we explain that bedaquiline is such a medicine. The MCC should be more open to considering pre-approval access for people facing high morbidity or mortality on current best approved treatments. This is not a frequent situation. It no longer applies to diseases like HIV or diabetes for example. But it does apply to drug-resistant TB. ### The evidence shows bedaquiline is promising The evidence showing that bedaquiline's benefits outweigh its risks needs to be developed, but so far it is promising. Bedaquiline is a diarylquinoline and is the first drug in this class for the treatment of drug-resistant TB, so there is unlikely to be any existing resistance to it. Bedaquiline inhibits mycobacteria ATP synthase. It is patented by Janssen Pharmaceuticals, a subsidiary of Johnson & Johnson.[^Patent2005] In a phase II randomised controlled trial bedaquiline was given to 23 patients and placebo to 24 patients, for eight weeks. All patients received standard MDR TB regimens as well. Bedaquiline significantly reduced the time to culture conversion over 24 weeks (HR 2.3; 95%CI:1.1-4.7; p=0.03). Nearly half the patients on bedaquiline became sputum-negative versus less than 10% of patients on placebo. The number of colony forming units was much lower in the bedaquiline arm too. Nausea was the only adverse event reported to occur significantly more often in the bedaquiline group (26% vs. 4%, p=0.04).[^Diacon2009] A study with two year follow up data of this trial has been published and confirms the initial promising outcomes.[^Diacon2012] An open-label safety trial of bedaquiline with about 200 patients has also been conducted. Janssen has presented 24 week data from this trial. The 2012 Pipeline Report explains: > The data indicated that adding bedaquiline to an individualized MDR-TB regimen was safe and well tolerated and resulted in an overall 81% culture conversion rate at week 24, with median times to culture conversion of 8 weeks for patients with MDR-TB, 12 weeks for patients with pre-XDR-TB, and 24 weeks for patients with XDR-TB.[^Pipeline2012] As far as interactions with antiretrovirals go, which is obviously an important concern in South Africa where many drug-resistant patients are co-infected with HIV, a small Phase I study found that bedaquiline is well-tolerated with efavirenz and that the effect of efavirenz on bedaquiline concentrations is unlikely to be clinically significant. Bedaquiline was associated with QT prolongation.[^Dooley2012a] The 2012 Pipeline Report further explains: > Janssen now plans to start a phase III trial of 600 subjects with sputum smear-positive pulmonary MDR- or pre-XDR-TB (confirmed by rapid diagnostic test). Participants in the first arm will receive 9 months of bedaquiline and a background regimen. Those in the control arm will receive placebo and the background regimen. Participants in a third rollover arm, which will capture the failures from the first two arms, will receive an individualized salvage regimen. The primary endpoint will be relapse-free cure at 15 months for those in the first two arms. The final analysis will look at relapse-free cure at 21 months. > Janssen is also taking into consideration TB/HIV-coinfection and pediatric drug-resistant TB in its development plans.[^Pipeline2012] ### The evidence base for bedaquiline is better than most other MDR TB drugs The South African MDR TB treatment guidelines recommend a regimen that includes kanamycin, ethionamide, pyrazinamide, levofloxacin and terizidone.[^SA2012] Other drugs like linezolid are also often used for MDR TB. The efficacy of pyrazinamide has been well established, but there is likely much resistance to it amongst MDR TB patients because it is also part of the standard first-line regimen. We searched for controlled clinical trials of the remaining drugs to treat TB, i.e. kanamycin, ethionamide, levofloxacin, terizidone and linezolid. **Kanamycin** We can find one clinical trial of kanamycin in people with TB, though it is more accurate to describe it as a prospective case-controlled study. It was published in 1958 and compared kanamycin to streptomycin in 162 patients. It does not appear to have been randomised and the two groups of patients appear not to have been matched at baseline. The data showing the effectiveness of kanamycin is no better, and perhaps worse, than the data on bedaquiline.[^Donomae1958] The available data shows that the side effect profile of kanamycin is much worse than bedaquiline. Kanamycin causes hearing problems in 3 to 10% of patients and it also causes kidney problems.[^Global2008] [^Dooley2012b] **Ethionamide** A tiny clinical trial of 27 people compared ethionamide against thiacetazone in 1963. Cycloserine was given to patients in both arms. Nine out of 14 versus three out of nine patients on the ethionamide and thiacetazone arms respectively had what the authors call "bacteriologically quiescent disease" after one year. The authors state that the ethionamide arm performed statistically significantly better than the thiacetazone one.[^Angel1963] A Japanese controlled clinical trial that compared ethionamide against prothionamide was published in 1968. However, since all patients also received isoniazid and streptomycin and nearly all patients sputum-converted in all arms of the trial, it is impossible to calculate the effectiveness, if any, of ethionamide in this trial.[^Coop1968] There are other clinical trials of drug-resistant TB patients that use ethionamide as part of a treatment regimen, but we can find no other clinical trial evidence in people with TB in which ethionamide is tested against a control. Ethionamide is associated with serious side effects. Liver toxicity in particular is common and may continue even after patients stop taking the drug.[^Global2008] It is also associated with peripheral neuropathy. **Levofloxacin** Besides a seven day early bactericidal activity trial, we can find no clinical trials of levofloxacin that have considered the drug for the treatment of MDR TB. It also has several side effects, including phototoxicity, glucose disturbances, QT prolongation and others.[^Global2008] **Terizidone** We can find one reference to possible clinical trials of terizidone in a 1972 paper written in Croation, but we are unable to get the paper.[^Zrilic1972] The evidence base for terizidone is poor.[^Dooley2012b] **Linezolid** Linezolid has been used in South Africa for drug-resistant TB for some time. Yet the first randomized controlled trial of linezolid in patients with drug-resistant TB was only published in October 2012 and it was a smaller trial (n=41) than the Phase II bedaquiline trial described above. The results are promising and significantly more patients taking linezolid sputum-converted compared to the controls, but the drug was also associated with more serious adverse events than bedaquiline.[^Lee2012] This is not a comprehensive literature review or comparison, but except for pyrazinamide the controlled clinical trial evidence supporting the use of bedaquiline for the treatment of MDR TB is better than any other medicine recommended for this indication in the South African treatment guidelines. For XDR and pre-XDR TB patients, the additional drugs that are often used have even less compelling evidence supporting their use than the ones discussed here. Surely, it is reasonable for people to request and receive bedaquiline to try and treat their drug-resistant TB infection. ## Precedents In Europe and North America there are several pre-approval access precedents, particularly with antiretrovirals. For example, more than 35,000 people received didanosine before it was approved by the FDA in 1991.[^Harrington2012] This was controversial but likely prolonged many lives. Other antiretrovirals were also available before approval. There are of course risks with pre-approval access. There were cases of didanosine-associated pancreatis during the drug's pre-approval phase. Thousands of people took adefovir as an antiretroviral but it ended up not being approved for HIV treatment. In South Africa, lopinavir/ritonavir (branded as Kaletra) was made available to patients on Section 21 authorisation before the drug was registered. Pre-approving access to bedaquiline would therefore not be an unprecedented step by the MCC. ## Responsibility for serious adverse events or treatment failure A concern with pre-approving drugs is who should bear responsibility for the risk of patients experiencing severe adverse events. It is our view that until a drug is registered, if it is used outside of a clinical trial setting as part of pre-approval access, then the pharmaceutical company that manufacturers, tests or holds the patent on the drug should not be responsible for the risk. This means that it is very important that doctors tell patients of the risk of taking an experimental drug. Patients have to be aware that the experimental drug they are taking has not yet been fully tested, that it might not work, that it might cause severe adverse events and that it might be worse than not taking it at all although this is unlikely. The one exception is if the pharmaceutical company held back important safety and efficacy data that might have influenced a patient's decision to take the experimental drug or a doctor's decisions to prescribe it. In that case, the pharmaceutical company must be held responsible. Because of the risk of taking an experimental drug and the need for patients to be properly informed of the risks, as well as the public interest to limit resistance to bedaquiline, the drug should only be made available to institutions which are likely to have the capacity to monitor patient adherence and inform them of the risk. In our view, health units run by or partnered with academic institutions and proven medical delivery organisations, for example Medecins Sans Frontieres, meet these criteria. ## The benefits of pre-approval access outweighs the risks There are benefits and risks of pre-approval access to bedaquiline. On the current evidence, the benefits of pre-approval access outweigh the risks. Pre-approval access is likely to give patients hope, increase their chances of being cured, reduce the time that they are infectious and possibly reduce their risk of death. The MCC should acknowledge the risks but give drug-resistant TB patients who attend well-run health facilities and who have been properly informed, the opportunity to add bedaquiline to their treatment regimen. **The original document was published on 24 November 2012. The following amendment was published on 21 December 2012.** # Post-publication amendment to Case for Bedaquiline Following the publication of the Case for Bedaquiline we became aware of a further phase II clinical trial of bedaquiline that we did not include. Information on this trial was made available in November in a report to the US Food and Drug Administration. [^FDA] In this trial 79 people were randomised to take bedaquiline and 81 to take placebo. All participants had MDR TB and were on a standard background regimen. Participants in the bedaquiline arm had significantly faster time to sputum conversion at 24 weeks (p<0.0001). This benefit was still present at 72 week follow-up. At week 24, 79% vs. 58% of people had sputum-converted on the bedaquiline and placebo arms respectively (p=0.008). However, a significant safety issue was reported. Ten people died on the bedaquiline arm and two died in the placebo arm (p=0.02, Fisher's exact test). This result is possibly a statistical anomaly but it is concerning and emphasises the need for a phase III study with adverse events as an endpoint. All but one of the deaths on the bedaquiline arm occurred after the drug was stopped and the time range over which the deaths occurred was wide, but bedaquiline has a long half-life and a causal effect cannot be ruled out. The only cause of death that was reported more than once was TB, which supports the possibility of the mortality result being a fluke. **End of amendment.** [^Janssen2012]: In July the drug was submitted for approval to the US Food and Drug Administration through its *Accelerated Approval* process. See *Janssen Research & Development Submits New Drug Application to FDA for Investigational Multi-Drug Resistant Tuberculosis Treatment Bedaquiline (TMC207).* [http://www.jnj.com/connect/news/all/janssen-research-and-development-submits-new-drug-application-to-fda-for-investigational-multi-drug-resistant-tuberculosis-treatment-bedaquiline-tmc207](http://www.jnj.com/connect/news/all/janssen-research-and-development-submits-new-drug-application-to-fda-for-investigational-multi-drug-resistant-tuberculosis-treatment-bedaquiline-tmc207) [^Section21]: Section 21 of the South African Medicines and Related Substances Act 101 of 1965 empowers the MCC to authorise the sale of unregistered medicine for specific purposes. This is commonly called a Section 21 authorisation. [^Goldacre2012]: This concern is articulated by Ben Goldacre with respect to the understandable and justified accelerated approval of AIDS drugs in the United States in the late 1980s and early 1990s in the United States. Unfortunately, this resulted in drug companies, sometimes aided by patient groups, using relaxed approval mechanisms to push through non-AIDS drugs that should have been better tested. Goldacre B. 2012. Bad Pharma. At page 137. [^Ahuja2012]: Ahuja SD et al. (2012) Multidrug Resistant Pulmonary Tuberculosis Treatment Regimens and Patient Outcomes: An Individual Patient Data Meta-analysis of 9,153 Patients. PLoS Med 9(8): e1001300. doi:10.1371/journal.pmed.1001300 [^Odonnell2009]: O'Donnell MR et al. Improved early results for patients with extensively drug-resistant tuberculosis and HIV in South Africa. Int J Tuberc Lung Dis. 2009 Jul;13(7):855-61. [http://www.ncbi.nlm.nih.gov/pubmed/19555535](http://www.ncbi.nlm.nih.gov/pubmed/19555535) [^Gandhi2009]: Gandhi N et al. High Early Mortality among HIV-infected Patients with Extensively Drug-resistant or Multidrug-resistant TB in Rural South Africa. 16th CROI, 2009. Poster abstract 784. [http://www.retroconference.org/2009/Abstracts/36299.htm](http://www.retroconference.org/2009/Abstracts/36299.htm) [^WHO2011]: World Health Organisation. Guidelines for the Programmatic Management of Drug-Resistant Tuberculosis: 2011 update. [http://whqlibdoc.who.int/publications/2011/9789241501583_eng.pdf](http://whqlibdoc.who.int/publications/2011/9789241501583_eng.pdf) [^Odonnell2010]: O'Donnell MR et al. High incidence of hospital admissions with multidrug-resistant and extensively drug-resistant tuberculosis among South African health care workers. Ann Intern Med. 2010 Oct 19;153(8):516-22. [http://www.ncbi.nlm.nih.gov/pubmed/20956708](http://www.ncbi.nlm.nih.gov/pubmed/20956708) [^Lushaba2011]: Lushaba, C. 2011. TB and me. Real stories of people living with multidrug resistant tuberculosis. [http://blogs.msf.org/tb/author/colisile/](http://blogs.msf.org/tb/author/colisile/) [^Harris2012]: Harris T et al. Aminoglycoside-induced hearing loss in HIV-positive and HIV-negative multidrug-resistant tuberculosis patients. South African Medical Journal, Vol 102, No 6 (2012). [http://www.samj.org.za/index.php/samj/article/view/4964/4128](http://www.samj.org.za/index.php/samj/article/view/4964/4128) [^Torun2005]: Törün T et al. Side Effects Associated with the Treatment of Multidrug-resistant Tuberculosis. The International Journal of Tuberculosis and Lung Disease: The Official Journal of the International Union Against Tuberculosis and Lung Disease 9, no. 12 (December 2005): 1373–1377. [^Patent2005]: Patent EP1527050. Filed 2002. Published 2005. Quinoline derivatives and their use as mycobacterial inhibitors. [http://www.google.com/patents/EP1527050A1?cl=en](http://www.google.com/patents/EP1527050A1?cl=en) [^Diacon2009]: Diacon AH et al. The Diarylquinoline TMC207 for Multidrug-resistant Tuberculosis. The New England Journal of Medicine 360, no. 23 (June 4, 2009): 2397–2405. [http://www.ncbi.nlm.nih.gov/pubmed/19494215](http://www.ncbi.nlm.nih.gov/pubmed/19494215) [^Diacon2012]: Diacon AH et al. Randomized Pilot Trial of Eight Weeks of Bedaquiline (TMC207) Treatment for Multidrug-resistant Tuberculosis: Long-term Outcome, Tolerability, and Effect on Emergence of Drug Resistance. Antimicrobial Agents and Chemotherapy 56, no. 6 (June 2012): 3271–3276. [http://www.ncbi.nlm.nih.gov/pubmed/22391540](http://www.ncbi.nlm.nih.gov/pubmed/22391540) [^Dooley2012a]: Dooley KE et al. Safety, Tolerability, and Pharmacokinetic Interactions of the Antituberculous Agent TMC207 (bedaquiline) with Efavirenz in Healthy Volunteers: AIDS Clinical Trials Group Study A5267. Journal of Acquired Immune Deficiency Syndromes (1999) 59, no. 5 (April 15, 2012): 455–462. [http://www.ncbi.nlm.nih.gov/pubmed/22126739](http://www.ncbi.nlm.nih.gov/pubmed/22126739) [^Dooley2012b]: Dooley KE et al. Old Drugs, New Purpose: Retooling Existing Drugs for Optimized Treatment of Resistant Tuberculosis. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America 55, no. 4 (August 2012): 572–581. doi:10.1093/cid/cis487. [^Angel1963]: Angel, J.H et al. A Controlled Comparison of Cycloserine Plus Ethionamide with Cycloserine Plus Thiacetazone in Patients with Active Pulmonary Tuberculosis Despite Prolonged Previous Chemotherapy. Tubercle 44, no. 2 (June 1963): 215–224. doi:10.1016/S0041-3879(63)80115-4. [^Pipeline2012]: Clayden P et al. 2012 Pipeline Report. [http://www.pipelinereport.org/browse/tb-treatments/bedaquiline-tmc207](http://www.pipelinereport.org/browse/tb-treatments/bedaquiline-tmc207) [^SA2012]: Republic of South Africa Department of Health. Guidelines for Management of Drug-Resistant Tuberculosis in South Africa. 2010. [http://www.tbonline.info/media/uploads/documents/mdr-tb_sa_2010.pdf](http://www.tbonline.info/media/uploads/documents/mdr-tb_sa_2010.pdf) [^Lee2012]: Lee M et al. Linezolid for Treatment of Chronic Extensively Drug-Resistant Tuberculosis. New England Journal of Medicine 367, no. 16 (2012): 1508–1518. [http://www.nejm.org/doi/full/10.1056/NEJMoa1201964](http://www.nejm.org/doi/full/10.1056/NEJMoa1201964) [^Harrington2012]: Harrington M. TAG at 20 - Part II: On a Darkling Plain—The Years of Despair. tagline Fall 2012. [http://www.treatmentactiongroup.org/tagline/2012/fall/tag-20-darkling-plain](http://www.treatmentactiongroup.org/tagline/2012/fall/tag-20-darkling-plain) [^Donomae1958]: Donomae I et al. Clinical studies of kanamycin treatment of pulmonary tuberculosis. Annals of the New York Academy of Sciences Volume 76, The Basic and Clinical Research of the New Antibiotic, Kanamycin pages 166–187, September 1958. [http://onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.1958.tb54705.x/abstract](http://onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.1958.tb54705.x/abstract) [^Global2008]: Global Alliance for TB Drug Development. 2008. Handbook of Anti-Tuberculosis Agents. [^Coop1968]: The Co-Operative Study Unit On Chemotherapy Of Tuberculosis Of The National Sanatoria In Japan. Comparison of the clinical usefulness of ethionamide and prothionamide in initial treatment of tuberculosis: tenth series of controlled trials. Tubercle. Volume 49, Issue 3, September 1968, Pages 281–290. [^Zrilic1972]: Zrilić V et al. Results of clinical trials of a new antitubercular agent, terizidone (Terivalidine). Plucne Bolesti Tuberk. 1972 Apr-Jun;24(2):89-98. [http://www.ncbi.nlm.nih.gov/pubmed/4565191](http://www.ncbi.nlm.nih.gov/pubmed/4565191) [^FDA]: Anti-Infective Drugs Advisory Committee Meeting Briefing Document. TMC207 (bedaquiline) Treatment of Patients with MDR-TB. NDA 204-384. 28 November 2012. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/Anti-InfectiveDrugsAdvisoryCommittee/UCM329260.pdf

We are living in a time of great change and excitement in TB drug development. The last year has witnessed a number of epochal changes, including the approval and rollout of the most rapid test for TB ever discovered, the GeneXpert; the combination TB drug studies in the relapse mouse model of Eric Nuermberger and Jacques Grosset at Johns Hopkins with support from the TB Alliance; the progression of TMC207 into late phase II and of OPC67683 into phase III; and the first new regimen EBA study, NC-001 also from the Alliance.

There are many organisations working in the TB field. Our selection of which ones to describe is open to criticism, but these do appear to be influential organisations on the international stage. We have deliberately left out local advocacy groups as well as the organisations that host the TB Online website. Global Fund to Fight AIDS TB and Malaria ---------------------------------------- The [Global Fund to Fight AIDS, TB, and Malaria](http://www.theglobalfund.org/en/ "Global Fund"), often referred to as the Global Fund, was founded in 2002 as a multilateral organisation that raises and distributes funds for HIV/AIDS, TB, and malaria programs in low- and middle-income countries. Its founders aimed to add to, rather than duplicate, existing global health institutions like the World Health Organization (WHO) and UN, and to create a faster and more “business-oriented” funding mechanism. The Global Fund provides funding based on proposals designed by countries themselves, and does not engage in project implementation. In addition, the Fund incorporates a broader set of actors than most traditional programs, as it partners with civil society and the private sector in addition to governmental actors. The Global Fund is often confused with the WHO and the UN, partly because these institutions are intimately involved with Global Fund activities through the provision of expertise and direction. Until 2009, Global Fund staff were officially WHO staff members, and the WHO continues to provide administrative services to the Fund. The Global Fund is organized into different structural levels. Based in Geneva, Switzerland, the Secretariat manages the grant portfolio, screens project proposals, and provides strategic direction. The Technical Review Panel is an independent group of international experts that meets regularly to evaluate proposals and provide funding recommendations to the Board. The Board, composed of a variety of stakeholders, is responsible for establishing strategies and policies, making funding decisions, and setting budgets. At the country level, the Country Coordinating Mechanisms (CCMs) consist of partnerships between the Global Fund and key actors involved in a given country’s response to the three diseases, including some or all of government, NGOs, the UN, and faith-based and private sector stakeholders. CCMs are responsible for project implementation, and they designate one or more in-country Principal Recipients to direct implementation or channel funding to other organisations. The Global Fund’s Trustee, which is currently the World Bank, manages the institution’s money. The Global Fund is thus a collaboration between developed countries, developing countries, the private sector, civil society and affected communities. Soon after its creation, the Global Fund became the chief multilateral global health funding organisation. Its international funding comes primarily from national governments, and it channels two-thirds of this funding to fight TB and malaria and a fifth to fight HIV/AIDS. The Global Fund now provides 20% of global funding for HIV/AIDS and 66% of funding for TB and malaria. From 2002 to the end of 2010, the TB programs financed by the Fund supported DOTS for a total of 7.7 million people. Its funded projects support more than 600 health programs in 150 countries. Stop TB Partnership ------------------- The [Stop TB Partnership](http://www.stoptb.org/ "Stop TB Partnership") (STBP) consists of more than 900 countries, national and international organisations, governmental institutions, NGOs, donors, and academics, working together to reduce the toll of TB worldwide and eliminate the disease as a public health problem. Established in 2001, STBP grew out of the Stop TB Initiative launched by the WHO in 1998. It was formed following the Amsterdam Ministerial Conference in 2000, which produced the Amsterdam Declaration to Stop TB. The organisation is structured into four main components. The Stop Partners’ Forum consists of a large number of collaborating governmental and non-governmental organisations and institutions - including The Union and the Foundation for Innovative New Diagnostics (FIND) - which come together every three to four years primarily for the purpose of information exchange. The last Forum was held in 2009 in Rio de Janeiro. Partner organisations have come together into 7 Working Groups (WGs), which form the second component of the Partnership. These WGs implement research, advocacy and/or operational activities in their specific area of expertise, and include: DOTS Expansion; TB/HIV; MDR-TB; New TB Drugs; New TB Vaccines; New TB Diagnostics; and Advocacy, Communications and Social Mobilization. The STBP also consists of a Coordinating Board, which provides governance, and the Secretariat, which is housed at the WHO in Geneva. The WHO is closely associated with STBP. As the housing institution, the WHO provides rules and regulations for organisational management. Secondly, as a leading agency in STOP TB with permanent representation in the Coordinating Board, the WHO provides guidance on global policy. The WHO’s Stop TB Strategy, which built on the success of its Directly Observed Treatment Short course (DOTS strategy, underpins the Stop TB Partnership's Global Plan to Stop TB 2006-2015. This plan provides a framework for engaging countries on action needed to implement the WHO’s Stop TB Strategy. The STBP has established collaborative relationships with a number of countries, for which it provides assistance that ranges from advocacy and resource mobilization to coordination of service delivery. The organisation also runs a Global Drug Facility (DGF) that provides TB drugs at low cost to developing countries. Global Drug Facility -------------------- The [Global Drug Facility](http://www.stoptb.org/gdf/ "GDF") (GDF) was established by the Stop TB Partnership in 2001 to facilitate the WHO’s DOTS strategy. It is housed in WHO headquarters in Geneva and managed by a small team in the Stop TB Partnership Secretariat. The GDF connects demand for TB drugs with supply and monitoring. Its Direct Procurement service provides first and second-line TB drugs to clients at low cost, while requiring adherence to DOTS. Both governments and NGOs, in collaboration with their respective Ministries of Health, can apply for GDF assistance. The provision of assistance is limited to programmes that have been approved by the Green Light Committee. All GDF services are provided by competitively outsourced partner companies. A six-month course of first-line TB treatment can be obtained at a price of between US$ 14 -18. In addition to low-cost, quality-assured TB medicines, the GDF also provides in-country technical support on drug management, registration, and supply issues; TB diagnostic kits; and grants consisting of free adult and paediatric anti-TB drugs to countries unable to secure these medications through government or alternative sources of funding. These grants are linked to TB programme performance. Currently, 93 different countries are receiving GDF drugs. The GDF has also recently begun working with the WHO, the Global Laboratory Initiative, and the Foundation for Innovative Diagnostics (FIND) to accelerate access to diagnostics for patients at risk of MDR TB. In this collaboration, the GDF’s role is to procure MDR diagnostic commodities. Green Light Committee --------------------- The [Green Light Committee](http://www.who.int/tb/challenges/mdr/greenlightcommittee/en/ "GLC") (GLC) is a component of the GLC Initiative, which was started in July 2011 by the WHO and the Stop TB Partnership out of a need to expand access to MDR TB treatment. The Initiative is comprised of the GLC, the WHO, the Stop TB Partnership’s Global Drug Facility (GDF), and organisational partners that provide financial and technical assistance. These partners include the Global Fund and UNITAID. The GLC Initiative is designed to support countries in the management of MDR TB. It aims to increase access to preferentially priced second-line drugs for the treatment of drug-resistant TB. The Committee is an expert advisory body that provides technical review of proposed drug-resistant TB treatment projects for the Initiative. The WHO is a permanent member of the Committee, while other representatives are normally drawn from the Stop TB Partnership’s Working Group on MDR TB. After reviewing proposals, the Commitee ‘green-lights’ projects that meet certain specifications, including adherence to WHO guidelines. Approved projects then receive access to quality-assured drugs at reduced prices. These drugs are procured through the GDF, which coordinates all procurement and delivery functions for GLC-approved programmes. In addition, the Initiative provides monitoring services to track the performance of all approved MDR TB programmes through annual site visits. Today, only programmes that have been approved by the GLC are allowed to obtain drugs from the GDF. In 2010, an estimated 13% of the market for second-line TB drugs was channelled through the GDF, while 6,000 patients were enrolled in GLC-approved treatment programmes. This is compared with an estimated 440,000 new cases and 150,000 deaths that year. To expand treatment for MDR TB, MSF recommends that procurement for GDF medicines no longer be restricted solely to GLC-approved programmes, in the recognition that all treatment programmes should be able to obtain quality-assured medicines at a reasonable cost.[^MSF] The Union --------- The Union (www.theunion.org/), formerly known as the International Union Against Tuberculosis and Lung Disease, is the oldest NGO dealing with health in the world. Its origins stretch back to 1867, when health experts convened in Paris to discuss TB, one of humanity’s oldest diseases. It was founded in the 1920s the International Union Against Tuberculosis when 31 countries came together to create a central resource for TB education, research, and advocacy. In the 1990s, the organisation underwent a period of expansion, and in 2002 became known as The Union. Today, The Union has 3,000 members in 152 countries and 12 offices worldwide. The organisation is headquartered in Paris and has offices around the globe that serve the Africa, Asia-Pacific, Europe, Latin America, Middle East, North America and South-East Asia regions. Regional experts in TB and lung disease come together in regional conferences that are held every two years. The Union is organized into a dual structure: the scientific institute pursues research, education, and technical assistance and is comprised of 300 experts working out of 12 different offices that. The federation is made up of 3,000 organisations and individuals grouped into several categories: constituent members (one per country), organisational members, and individuals. Members of the institute and federation come together to participate through the General Assembly. The Union expanded its activities beyond TB to include HIV, tobacco control, lung disease, and other issues. It provides technical assistance, education, and training, and conducts research in more than 70 counties each year through five scientific departments: Tuberculosis, HIV, Lung Health & Non-Communicable Diseases, Tobacco Control and Research. In 2004, the organisation created the International Management Development Programme in 2004 to build the capacity of public health programmes in low-and middle-income countries. FIND ---- The [Foundation for Innovative New Diagnostics](http://www.finddiagnostics.org/ "FIND") (FIND) is a non-profit foundation with headquarters in Geneva, and regional offices in Kampala, Uganda, and New Delhi, India. The organisation was launched at a meeting of the World Health Assembly in 2003. FIND aims to provide developing countries with innovative, affordable, and efficient diagnostic products, which are the tools that identify which patients are sick with which disease. Currently, the most widely used TB diagnostic is sputum smear microscopy, but there is an urgent need for the development and implementation of more accurate and efficient diagnostic tools to accelerate the diagnosis of non-resistant and drug-resistant TB infections. The creators of FIND recognized that the lack of effective diagnostic tests is one of the greatest obstacles to the control of diseases like TB in the developing world. FIND is a Product Development Partnership (PDP) that collaborates with public, private, and academic sectors to drive the development of diagnostics. A large component of FIND’s work consists of supporting the research and development of promising diagnostics by providing expertise, capacity, and facilities, and by overseeing the evaluation and demonstration of these diagnostics in laboratory and field trials. After the WHO approves a diagnostic technology, FIND works with its partners to collect evidence for expansion and supports the widespread implementation of the diagnostic method. FIND also collaborates with public health authorities in developing countries to assist with the investigation of the feasibility and impact of new technologies. The design, development, manufacture, evaluation and demonstration of diagnostic tools, however, are achieved entirely through its partner organisations. FIND has contributed to efforts to develop the Gene Xpert diagnostic TB test. The organisation initially focused its efforts solely on TB diagnostics, but has since expanded its activities to include malaria and human African trypanosomiasis (HAT), also known as African sleeping sickness. With the financial support of the Bill & Melinda Gates Foundation, FIND and the WHO have recently begun collaborating in the development of much needed diagnostic tests for sleeping sickness. TB Alliance ----------- The [Global Alliance for TB Drug Development](http://www.tballiance.org/ "TB Alliance"), commonly called the TB Alliance, was established in 2000 as a non-profit Product Development Partnership (PDP) engaged in the search for and development of TB cures and experimental drugs. The organisation was conceived at a February 2000 meeting in Cape Town, South Africa, where 120 representatives from industry, academia, donors, and NGOs came together to discuss the urgent need for new TB treatments. At the time, efforts to develop TB drugs had stagnated and there were no medicines undergoing clinical testing. The TB Alliance has helped reinvigorate efforts to develop new cures. Today, the organisation leads the advancement of the most comprehensive portfolio of TB drug candidates in history, which includes more than 20 active development programmes and 3 compounds in late-stage clinical testing. Headquartered in New York and with regional offices in Brussels, Belgium and Pretoria, South Africa, the TB Alliance builds partnerships with a broad range of public and private stakeholders, including pharmaceutical companies, universities, and other research laboratories around the world. The organisation conceives of itself as a neutral third party able to broker partnerships between relevant actors, and has had particular success in developing innovative collaborative relationships with pharmaceutical companies. As a PDP, the TB Alliance retains direct oversight of its projects, although much of the laboratory and clinical work is done though external research facilities and contractors. It manages a portfolio of experimental drugs using a variety of licensing agreements. The TB Alliance currently has several experimental TB drugs in the pipeline. It has global exclusive rights to PA-824 for the treatment of TB in an agreement with Chiron (now part of Novartis) in 2002. The TB Alliance is currently conducting phase II clinical testing of PA-824. In addition, the TB Alliance gained a royalty-free license to develop TMC207 for drug-sensitive TB from the pharmaceutical Tibotec. TMC207 is also undergoing phase II clinical testing. SATVI ----- The [South African Tuberculosis Vaccine Initiative](http://www.satvi.uct.ac.za/ "SATVI") (SATVI) is the largest TB vaccine research group on the African continent. Established in 2001, SATVI is housed within the Institute of Infectious Disease and Molecular Medicine of the University of Cape Town. Its field site is located in the Boland region outside of Cape Town, which has one of the highest recorded TB rates in the world. It is comprised of professors, clinicians, epidemiologists, immunologists, and other professionals and students. SATVI aims to develop new and effective vaccination strategies against TB, and is currently conducting standard clinical trials of several novel TB vaccine candidates, including MVA85A. Its recent projects include a phase II study, published in 2010, that evaluated the safety and immunogenicity of MVA85A in healthy children and infants after BCG vaccination at birth. SATVI is currently conducting a phase IIB, double-blind, randomized clinical trial of MVA85A/ AERAS-485 to evaluate the safety and efficacy in preventing TB amongst BCG-Vaccinated, HIV-negative Infants. In addition to conducting clinical trials, the organisation engages in research to address clinical, epidemiological, immunological, and human genetics questions in TB vaccine development. BCG World Atlas --------------- The [BCG World Atlas](http://www.bcgatlas.org/ "BCG World Atlas") is an informational, interactive website on the BCG vaccine for TB. The website was originally developed out of a need to provide accessible, up-to-date information on the vaccine; while most experts agree that BCG is effective against severe forms of childhood TB, its efficacy against TB in adults is highly variable. As a result, countries have divergent policies with regard to BCG vaccination. The website creators launched the first searchable, online database of global BCG vaccination policy and practices in 2008. By 2010, the database contained information on current and previous policy and practice for 180 countries. BCG World Atlas serves as a resource for clinicians, policymakers, researchers, and the public, providing information that could be useful for interpreting TB diagnostics and developing new TB vaccines. TB Drug Resistance Mutation Database ------------------------------------ The [TB Drug Resistance Mutation Database](http://www.tbdreamdb.com/ "TB Drug Resistance Mutation Database") was established by health experts at the Harvard School of Public Health in 2009. Its creators recognized the urgent need for better and more rapid diagnostics for drug resistant TB. In particular, they aimed to facilitate the development of diagnostic methods based on genetic sequencing of specific mutations associated with resistance to certain TB drugs. The website makes information about these mutations accessible to the public through a comprehensive database of the genetic polymorphisms associated with first- and second-line drug resistance in TB bacteria. The most common mutations and the frequency of each mutation have been compiled and organised according to major groups of TB drugs. The website serves as a useful tool for the development of sequence-based TB diagnostics that detect mutations, and for the structural mapping of mutations to illuminate bacterial mechanisms of drug resistance. [^MSF]: DR-TB Drugs Under the Microscope. MSF Report. March 2011.

Activists from across the world have written an open letter to Professor Rifat Atun, chairman of the co-ordinating board of the Stop TB Partnership expressing concerns about the current and future governance of the organisation and its relationship with the World Health Organisation.

Statement by the Treatment Action Campaign, the HIV Clinicians Society of Southern Africa, Médecins Sans Frontières, SECTION27 (incorporating the AIDS Law Project), HIV i-Base, Wits Reproductive Health and HIV Institute (WRHI), Jhpiego and the Centre for the AIDS Programme of Research in South Africa (CAPRISA)

Lihle Dlamini is the Deputy General Secretary of the Treatment Action Campaign. Her HIV activism started in 2002 when she was diagnosed with TB and experienced the horrors of the South African public health system.