Despite the fact that it has been around since antiquity, been virtually wiped out in the developed world, and is both preventable and curable, tuberculosis (TB) continues to be the second most deadly single infection in the world after HIV.
Transmitted through the air from person to person, the bacterium killed around 1.4 million in 2010 and is currently thought to be affecting 12 million across the globe. One third of the world’s population is thought to have latent TB, and TB is among the top three causes of death for women aged 15 to 44 worldwide.
Médecins Sans Frontières (MSF) this week released a press statement calling for urgent action to avert a potentially global crisis of multidrug-resistant tuberculosis (MDR-TB), a much more resilient form of the disease that does not respond to first-line drugs and requires a more toxic and lengthy treatment of up to two years.
One of the regions worst affected by MDR-TB is southern Africa, where countries face a double health crisis of TB and HIV; HIV weakens the immune system, making sufferers more susceptible to TB.
It is no coincidence, for example, that South Africa is among the top four countries in the world in terms of both HIV-prevalence and number of TB-sufferers. Nor is it simply bad luck that the South African province of KwaZulu Natal, the area with the highest prevalence of HIV in South Africa (and in fact the world), also has the highest number of MDR-TB cases in the country.
While being one of the world’s most heavily TB-burdened countries in the world, however, South Africa is also leading the way on MDR-TB policy and has shown that MDR-TB is not a problem without a solution.
“South Africa is at the forefront of the fight against drug resistant TB”, Gilles Van Cutsem, Medical Coordinator and acting Head of Mission for MSF in South Africa and Lesotho, explained to Think Africa Press – their policies have shown that “drug resistant TB can be treated”.
Whether these same techniques will be viable for other low and middle-income countries – in which 95% of TB cases are located – is another matter.
In Khayelitsha, a Cape Town township, a joint project between MSF and local government improved case detection from 118 cases in 2006 up to 231 in 2009, reduced time between diagnosis and treatment from 71 days in 2007 to 33 days in 2010, and improved survival rates to levels now envied by surrounding provinces.
On the one hand, this progress is down to intelligent management of resources, personnel and patients. Whereas previously, all TB-sufferers had to go to overcrowded central facilities where waiting lists could be months long and where patients faced a mandatory six months in a kind of quarantined prison, diagnosis and treatment has now been decentralised to peripheral health centres. This has enabled more patient-centred, sensitive and effective approaches to be employed, yielding promising results. These policies can be relatively easily emulated across South Africa and in other countries.
On the other hand, however, absolutely crucial to South Africa’s successes has also been the emergence on the scene of a new cartridge-based diagnostic device called GeneXpert.
GeneXpert, made by Cepheid, was endorsed by the WHO in 2010 as a “major milestone for TB diagnosis and care” and hailed as revolutionary by experts. It allows diagnoses to be made in around 90 minutes rather than the several weeks needed with sputum smear tests, its sensitivity is about 98% compared to smear microscopy’s 35-80%, and it requires very little technical training to operate.
“By introducing GeneXpert, we can massively increase diagnosis, and the difference this can make is tremendous”, explained Van Cutsem. With faster diagnostic tools, more cases can be detected and treatment can be started sooner, leading to higher chances of survival and a reduced period in which the disease can be transmitted.
The main stumbling block to GeneXperts being shipped out to TB-burdened countries around the world to the benefit of tens of millions of people, however, comes down to money.
“GeneXpert is an extraordinary test which can have an enormous public health benefit”, says Van Cutsem, “but in most of the countries we work, ministries of health do not have the funding to afford the test at the moment”.
The cheapest machine is thought to cost around $20,000 and each cartridge around $20. MSF’s attempts to convince Cepheid to lower costs to make its life-saving products affordable in areas where need is at its most desperate have reportedly fallen on deaf ears. Cepheid, the only company producing the diagnostic test is, according to Van Cutsem, “abusing its monopoly power”.
“Cepheid decreasing the price of GeneXpert is totally possible,” he insisted. “A company selling a life-saving diagnostic must make a choice between the highest possible profits and – knowing you have in your hands a test that can save hundreds of thousands of life – at least some level of ethical responsibility.”
And it is not only diagnostic tools but essential drugs that are often prohibitively expensive, especially when it comes to MDR-TB. MDR-TB treatment is not only lengthy, toxic and riddled with side-effects, but costs as much as $9000. Research is urgently needed to develop more tolerable treatment and more price control necessary to make the treatment affordable.
Funding for research, treatment and diagnosis, however, has not been as forthcoming as necessary. In fact, last November it was announced that the Global Fund was cancelling Round 11 of funding due to the failure of donor countries to respect their commitments of aid.
Especially given the spread of MDR-TB, this is, according to Van Cutsem, a “very poor calculation”. “If we decrease funding now,” he explained, “the problem will expand and in a few years we will be faced with a much bigger problem which will require even more funding”.
To avoid this, says MSF President Karunakara, “we need new drugs, new research, new programmes, and a new commitment from international donors and governments”.
With 140,000 MDR-TB sufferers worldwide – less than 5% of whom have access to proper diagnosis and only 10% of whom have access to treatment – “the world can no longer sit back and ignore the threat of MDR-TB. We must act now”.
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