Charles Ssonko from Médecins Sans Frontières reflects on the challenges of treating TB in unstable settings.
Amid the justified excitement surrounding the development of the first new drugs to treat TB in over 50 years it is worth remembering on World TB Day (March 24th) that in countries affected by conflict and instability the biggest challenges remain lack of access to diagnosis and treatment.
Working as a doctor treating TB and HIV for Medecins Sans Frontieres (MSF) has taken me to many areas with huge health system challenges. But these were nowhere more apparent than in the remote conflict-affected areas of Shabunda and Kalonge in the South and Mweso and Kitchanga in the North Kivu provinces of Democratic Republic of Congo (DRC).
In many conflict settings TB and HIV remain hugely neglected by international agencies while conditions favour escalation of these diseases. Health services stop functioning; there is overcrowding and migration, lack of nutrition, ongoing transmission due to few services and lack of access to treatment and potentially increased HIV transmission.
In Mweso and Kitchanga the conflict had left health infrastructure damaged leaving fewer staff from the Ministry of Health working with the MSF project staff struggling to treat TB as well as responding to patients with emergency health needs. Shabunda, while not currently in the middle of conflict, remains isolated and health care is extremely limited. I managed to get to Shabunda by a chartered flight, but this is not an option for most of the people living in this poor rural area. One patient told me that the only way to get from Shabunda to Bukavu, the capital of South Kivu, for treatment is by foot – a walk of over 500 km that takes around 2 weeks – as the roads are so bad especially during the rainy season.
During the time I was in Shabunda there were shortages of TB drugs and I saw patients who had missed several weeks of treatment as a result. TB drugs are transported from the capital of DRC, Kinshasa, by plane and are first routed through the eastern DRC city of Goma, spending several weeks there before getting to Bukavu, where transport is organised to finally get the drugs to Shabunda or Kalonge. There are always delays as South Kivu province does not have the money to charter a plane for a flight to Shabunda and relies on international partners. MSF is ensuring that there are extra TB drug stocks for patients, but there are importation restrictions, with drugs taking a long time to arrive. Those that do are only sufficient to treat a small proportion of the population in the region.
These delays put patients at a greater risk of developing drug-resistant (DR) TB. Treating DR-TB in these settings is possible but still difficult; new models of care are urgently needed such as the simplified shorter and less toxic 9 months Bangladesh regimen. Resistance to TB drugs is not routinely tested in most parts of DRC due to lack of point-of-care tests and the difficulty in transporting samples for analysis to Kinshasa or abroad. This has slowed down efforts to scale up DR-TB treatment in many parts of the country. Test systems such as GeneXpert that can rapidly diagnose TB and DR-TB remain expensive to buy and to run. GeneXpert machines for example cost US$17,000 each and the cost of each test is $US9.98 in countries eligible for concessional pricing. They also require a stable electricity supply, which is absent in these parts of DRC, and means that the additional cost of a generator and power stabilisers is needed. However, TB REACH is currently scaling up GeneXpert equipment in several locations in North and South Kivu such as Baraka and Goma.
In DRC there is a high rate of coinfection of HIV and TB. Diagnosing and treating HIV is hindered by the same issues as in TB – lack of tests for HIV and ruptures in antiretroviral drug supplies exposing patients to potential resistance. This undermines efforts to integrate TB and HIV and provide timely treatment for these patients. Currently MSF is trying to implement simplified treatment guidelines using a one-stop-shop model of care where patients are treated for HIV and TB by the same health professional at the same time, but many barriers remain.
Working in unstable settings requires continuous assessment of the security situation and strong communication systems in order to obtain timely information. If the security situation becomes too dangerous then MSF can be forced to leave health projects. To ensure that treatment interruptions are minimised, MSF has developed contingency plans to ensure uninterrupted supplies of TB and HIV drugs. These involve guaranteeing an extra security stock of essential drugs in case supply is interrupted; establishing alternative safe posts for drug storage and supply in case of emergency; and a communication system to track patients and assess outcomes when stability returns. In some hospitals, patients can be admitted to avoid violence, but provision of sufficient food and shelter may not be possible. Contingency plans for patients include: education on the danger of interrupting treatment and how to seek care from other health units in case of displacement; providing personal identification (e.g. a TB ID card) so health workers in other units know which drugs to give, the phase of treatment, the length of treatment still needed and side-effects; use of public communication networks to tell patients about imminent interruptions of care and alternatives available; and provision of flexible long-term drug supplies with treatment support from family members and community health workers.
WHO has called for the scaling up of effective TB treatment for all including DR-TB treatment. If this ambition is to be realised, then there is an urgent need to develop and roll out innovative, feasible and affordable models of care as well as simpler treatment guidelines (ie the 9 months regimen for MDR-TB) and rapid diagnostic systems for people living in regions affected by conflict and instability.
Charles Ssonko is a medical doctor working as a TB/HIV programme advisor for Médecins Sans Frontières (MSF) UK. His previous experience includes working with TB and HIV in Africa, Asia, eastern Europe and the Caribbean. Dr Ssonko completed his medical degree at Makerere University, Uganda and a Masters in Public health at the London School of Hygiene and Tropical Medicine, UK.