KHOPOTSO: Among a plethora of factors, two possibly pose a serious threat to national Tuberculosis Control Programmes. One is the fact that about 14 million of the world’€™s TB carriers also have HIV. The other is the emergence of Extensively Drug-Resistant (XDR) Tuberculosis in some 40 countries, including in South Africa. Meeting in Cape Town for the World Conference on Lung Health last week, health care personnel, scientists and activists alike called for the integration of TB and HIV public health sector programmes to deal with the ‘€œdual epidemic’€ of HIV and TB. Sharon Ekambaram, Director of Doctors without Borders, MSF South Africa, shares some of the features of such a programme.

SHARON EKAMBARAM: Getting more people living with HIV tested for TB and for those living with TB tested for HIV; integrating and decentralising TB and HIV services; and preventing and treating drug-resistant TB. And for us in South Africa, we would want to see how the National Strategic Plan can have a comprehensive approach to dealing with both HIV and TB.

KHOPOTSO: In its new guidelines for TB control, the South African Department of Health allows for the systematic screening of vulnerable patients for drug-resistant TB. These include people living with HIV. It is estimated that in South Africa, 6000 cases of Multi-Drug Resistant TB occur, annually. One in ten of these cases are XDR TB. Patient resistance to medication, coupled with patients’€™ non-compliance with treatment can lead to drug resistance. Add to that a contributor called ‘€œdirect transmission,’€ and you have a potentially huge problem. Dr Eric Goemaere works with Doctors without Borders, in the Western Cape township of Khayelitsha where the organisation identified 200 MDR TB cases in the last two years.

Dr ERIC GOEMAERE: Actually, nowadays in South Africa we have a very strong other mechanism happening, which is direct transmission. Direct transmission means that people are developing as (a) first TB episode, resistant TB. In a place like Khayelitsha, 30% – a third of all cases – actually never had TB before. They cannot be accused of taking treatment in an improper way. They were contaminated immediately by a resistant strain.

KHOPOTSO: This phenomenon can be better explained by the fact that the TB bacteria travels via the air as we cough, spit or sneeze; and that it can be easily inhaled. The diagnosis of MDR TB is done in the laboratory and is not a simple process. It can take up to eight long weeks to successfully diagnose. It’€™s even more difficult to diagnose in people with HIV. But while improved diagnostics are needed, there is also a dire need for better treatment regimens.

Dr ERIC GOEMAERE: The treatment guidelines say that you have to use, at least, five drugs. Four out of them need to be so-called ‘€œclean drugs’€, (which) means drugs that patients have not been exposed to.  

KHOPOTSO: But the choice of drugs is limited. Two of the key drugs used in the treatment of MDR-TB  are Rifampicin and Isoniazid, also known as INH. If a patient develops resistance to these two, then they are said to have XDR TB.

Dr ERIC GOEMAERE: And then we try to complement the regimen with drugs called Ethionamide, PAS (and) Cycloserine ‘€“ which actually are not new drugs at all. They are very old drugs that were abandoned when Rifampicin (and) INH came into the market. They were abandoned because they were just too toxic and not efficacious enough’€¦ We are left to – with those patients – propose (to) them to come back to those abandoned toxic drugs because we have no alternative.

KHOPOTSO: Harvard Medical School’€™s Dr Nicole Mitnick believes there need to be large-scale international clinical trials network to test new drugs for MDR TB.  

Dr NICOLE MITNICK: Most clinical trials are conducted in resource-rich countries, and there’€™s very little MDR TB in those places. There has been very little attention to, or interest in, developing new drugs for MDR TB through clinical trials.

KHOPOTSO: Dr Tido von Schon-Angerer, Executive Director of Doctors without Borders in Geneva, has called on business to participate and for governments to show leadership in the effort against TB.

Dr TIDO VON SCHON-ANGERER: At the moment $200 million is spent every year on research for new tools for TB, and this needs to be increased, at least, five-fold to really rise to the challenge that we have. There’€™s very little commercial interest and governments are certainly not doing enough in this. So, there’€™s a great need for public leadership, here’€¦ We need this kind of political framework and commitment very urgently to really address the TB challenge that we have today.