KHOPOTSO: It’€™s estimated that in South Africa there are 6000 new cases of drug-resistant tuberculosis annually. About 10% of these cases are classified as the super TB strain, known as Extensively Drug-Resistant (XDR) TB. But experts say this figure could well be way short of the true extent of the country’€™s drug-resistant TB epidemic. These are only estimates and, in addition, not all carriers are able to reach the health system to be diagnosed. What is particularly worrisome is that drug-resistant TB can be transmitted to others even if they have never had primary TB before. Dr Eric Goemaere has seen this first hand in the Western Cape township of Khayelitsha where he works with the MSF (Doctors without Borders) mission.

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 first TB episode, resistant TB. In a place like Khayelitsha, 30% – a third of all cases ‘€“ actually never had TB before. So, they cannot be accused to have taken treatment in an improper way. They were contaminated immediately by a resistant strain.

KHOPOTSO: Over the last two years, the MSF mission in Khayelitsha has enrolled almost 300 patients with Multi Drug-resistant TB. MDR TB develops when treatment using two drugs commonly used for first time infection, Rifampin and Isoniazid, fails to alleviate their symptoms. This occurs when a health professional does not prescribe proper treatment regimens or when a patient is unable to adhere to therapy. XDR TB in turn is MDR TB that doesn’€™t respond to all first line drugs for primary TB and also has resistance to two of the major classes of the second line medicines for MDR TB. This is no new phenomenon, but the problem is of particular concern to people with HIV, particularly in resource-poor regions, such as in Africa.

Dr ERIC GOEMAERE: The reality is exploding in our faces. Resistant TB was around for a long time. It was just a hidden reality. It remained unknown. You could say, ‘€˜where did those patients disappear?’€™ Basically, the majority of them died ‘€“ mainly the co-infected ones ‘€“ (with) TB and HIV. They died and they were a mortality statistic.

KHOPOTSO: When XDR TB was first identified in 2005 in KwaZulu-Natal’€™s Tugela Ferry, all 53 patients had AIDS. Only one of them survived. A range of factors have led to the increase in drug-resistant TB, both in general and among HIV-infected individuals.

Dr ERIC GOEMAERE: One is called amplification. Amplification is when a patient is progressively developing resistance due to an unsatisfactory regimen. So, the TB develops further resistance because the regimen they are using is not suppressive’€¦ But there is another way and that’€™s the usual way that was recognised up to now. This problem of resistant TB is a problem linked to the fact that TB control programmes are not tight enough’€¦ people are defaulting their treatment or are not taking their entire treatment. The cure rate is too low’€¦

KHOPOTSO: Goemaere added that the method and time it took to diagnose patients that are at risk have also contributed to the scourge. But more strikingly, he says, is that patients stand the risk of cross-infecting one another with various strains of tuberculosis when confined in the same institutions meant to nurse them back to good health, such as specialist drug-resistant TB centres.      

Dr ERIC GOEMAERE: In fact, the catastrophe of Tugela Ferry was in great deal a nosocomial infection. Those patients, when they are sent into a central hospital, are busy infecting themselves. They are just getting worse because some of them are MDR, some of them are partially XDR, and some of them are XDR. And as long as they are mixed there, it just goes further… Also, those central hospitals are fully booked in all of the provinces. So, you have long delays before you can hospitalise a patient.            

KHOPOTSO: The latter results in the delay of the onset of treatment for patients. But it’€™s not all gloom and doom. There are things that can be done to improve the way TB is being treated, says Sharon Ekambaram, Director of the Johannesburg MSF office.  

SHARON EKAMBARAM: I think we want clear statements looking at improving infection control, 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’€¦ We would want to see how the National Strategic Plan (for HIV and AIDS) can have a comprehensive approach to dealing with both HIV and TB’€¦ I think what we need right now is political will. We need a vision, we need research and funding and action and activism on dealing with TB and HIV.            

KHOPOTSO: The emergence of Extensively Drug-Resistant Tuberculosis was a time bomb waiting to explode. In over forty years, scientists have not developed any new treatment regimens. Governments relaxed their efforts to strengthen their TB control programmes as they concentrated their resources on HIV/AIDS. But with TB and HIV being so closely connected, governments need to tackle both diseases together more effectively.