Guest post by Bern-Thomas Nyang’wa, a Malawian public health doctor working as a TB Implementer for Médecins Sans Frontières (MSF). Bern provides clinical and programmatic field support to start or improve MSF drug-resistant tuberculosis programmes in Africa, Latin America, central Asia and the Caucasus.
Being a Malawian medical doctor, a public-health specialist, living in London and attending a tuberculosis conference in Lille is already an exciting mix with its own sweet and sour moments. The 42nd Union World Conference on Lung Health however beat my expectations by a huge margin. I will take you through the rollercoaster of emotions that I went through as I attended different sessions during this conference.
It is now almost a year since WHO recommended the use of Xpert MTB/RIF for the rapid diagnosis of tuberculosis and rifampicin resistance, so what is the exciting news? In South Africa and Tanzania, they have been able to confirm tuberculosis and even drug resistance in children with Xpert MTB/RIF on sputum induction and gastric aspiration samples; in Uganda they use solar panels to power the GeneXpert machine in rural health facilities and do not even need air-conditioning! At this point I am dreaming about using this revolutionary machine in Médecins Sans Frontières’ (MSF) programme in Bouguila, Central African Republic, on a group of children who are malnourished, HIV-positive and coughing. If only we could confirm or rule out that they had tuberculosis, they would not need to take so many tablets with so many unknown interactions in children. I then am jerked awake by the Symposium on the rising caseload of paediatric drug-resistant tuberculosis, the message is clear: we are not diagnosing and reporting tuberculosis in children and let alone drug-resistant tuberculosis. When we do, the drug formulations are not adapted and are expensive.
Then the frustrations of a presenter on tuberculosis/HIV are summarised in a slide which says “If a bacterium (Mycobacterium tuberculosis) and a virus (HIV) can collaborate effectively, Why can’t we?”. This question takes me to my last visit to MSF’s programme in Abkhazia (Georgia) where historically health-care is in silos and collaboration, let alone integration, seems far-fetched. However, successes have been reported in Malawi and South Africa so I think we can get there.
The depressive frown starts to disappear from my brow when I listened to the scaling-up plans for India, the second-largest burden of drug-resistant tuberculosis is being tackled head on, with the support of private practitioners. China is doing the same, with innovative financing using health insurance schemes increasing access even to rural areas. As USAID starts to explain the inevitable drop in financing my palpitations return but these are quickly calmed by the knowledge that the 7 billion US dollars needed to treat drug-resistant tuberculosis outlined in “Towards universal access to diagnosis and treatment of multi drug-resistant and extensively drug-resistant TB by 2015” can be covered. There are worrisome budget trends from South Africa, but the economists told us that the 0.14 billion US dollars already pledged by international donors could cover the needs of all the low-income high-burden countries while Brazil, Russia, India, China and South Africa should be able to cover their own costs.
MSF, Treatment Action Group and Partners in Health organised a side meeting to discuss their joint report on “An evaluation of drug-resistant TB treatment scale-up”. The conclusions were that the global initiatives such as GLC (Green Light Committee), GLI (Global Laboratory Initiative) and GDF (Global Drug Facility) were massively underperforming. GLC had already responded to the situation and was no longer the limiting factor in accessing drugs, GDF also accepted some shortfalls and was working on them – especially negotiating to reduce the price of expensive drugs such as capreomycin even though they are already off patent. Is the use of non-WHO pre-qualified drugs a solution? Some strongly thought so but perhaps we won’t need to go down that route as was hinted during the climax of the conference, which was for me the last session, on clinical trials of new drugs and regimens for multi- and extensively drug-resistant tuberculosis. When all the scientific gibberish is weeded out, the message from this session was clear: a single regimen that will cure the currently-termed drug-sensitive and drug-resistant tuberculosis is not too far over the horizon. This regimen will not be dependent on rifampicin and isoniazid but on newly discovered drugs, perhaps TMC207, PA824 or others.
In the meantime however, Andrew Nunn during the Sir John Crofton lecture asked if we could identify certain patients, perhaps smear-negative who require shorter treatment regimens. Armand van Deun reminded us that multi- and extensively drug-resistant tuberculosis have been treated with a 9-month regimen in Bangladesh and some West African countries with results much better than the current WHO-recommended 24 months.
Faces of some drug-resistant tuberculosis patients come to me and I realise that the comfort of Lille is so far away from their realities but I’m reassured that the next time I see them, I will talk with much more hope and expectation. Although some of the breakthroughs may come too late for some but surely we will achieve the ambitious STOP TB 2012 aim of zero tuberculosis deaths in my life time!