Your daily Selection of IRIN Africa PlusNews reports, 1/5/2005

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U N I T E D N A T I O N S

Office for the Coordination of Humanitarian Affairs

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[These reports do not necessarily reflect the views of the United Nations]

CONTENT:

1 - AFRICA: Rethink urged over TB treatment

1 - AFRICA: Rethink urged over TB treatment

JOHANNESBURG, 4 January (PLUSNEWS) - In the crowded wards of African

hospitals, coughs and bony bodies tell the story of a deadly return.

Tuberculosis (TB), supposedly defeated 40 years ago, is back, riding on

the AIDS epidemic, and the world is ill-prepared, says the relief agency

Medecins Sans Frontieres (MSF).

In its study 'Running out of Breath? TB Care in the 21st Century', MSF's

Campaign for Access to Essential Medicines urges a radical rethink of the

global approach to the disease.

TB kills two million people every year, nearly all in developing

countries. Yet TB, if detected early and treated, is curable.

For HIV-positive people, TB is the most frequent opportunistic infection

and the leading cause of death. The scale of the problem is dramatic, with

some 12 million people co-infected with HIV and TB, two-thirds of whom

live in sub-Saharan Africa.

" National TB programmes are not coping with the burden, " said Dr Gilles

van Cutsem, who runs an AIDS/TB clinic for MSF in the South African

Township of Khayelitsha.

The problem is that the global anti-TB strategy - Directly Observed

Treatment Short-course (DOTS) - was designed before the full impact of the

AIDS epidemic on over-stretched health services was fully appreciated.

Launched by the World Health Organization (WHO) in 1994 and now

implemented in 180 countries, DOTS has improved TB detection and treatment

compliance, but reaches less than one-third of TB patients worldwide,

according to the New York-based Global Alliance for TB Drug Development.

" HIV/AIDS has transformed the landscape of TB care and control, " said Dr

Francine Matthys, TB advisor for WHO.

DOTS targets active pulmonary TB, the most infectious strain of the

disease, but people living with HIV/AIDS are more likely to have latent

and extra-pulmonary TB, which the standard diagnostic test fails to pick

up. Undetected and untreated, TB is the number one killer of HIV-positive

people.

" HIV-positive patients with TB are second-class citizens for national TB

programmes, " remarked van Cutsem.

Newer tests used in rich countries are more effective in detecting all

kinds of TB, but are also more complex and expensive. " What we need is a

simple, field-adapted test that delivers reliable results in even the most

resource-poor settings, " Matthys told PlusNews.

TB therapy involves a daily pill for up to eight months, long after

symptoms disappear. Because stopping treatment prematurely creates drug

resistance - a growing problem worldwide - DOTS was introduced, with a

health worker watching the patient take their pills for at least two

months, and providing regular monitoring afterwards.

This is labour-intensive and time-consuming for both health workers and

patients. It also means that DOTS can only be properly implemented in the

most stable settings. DOTS fails, for example, with nomads, migrant

workers, refugees and internally displaced people.

DOTS also contradicts the approach of antiretroviral treatment where AIDS

patients pop their daily pill on their own and have " treatment buddies " to

remind them.

Another problem is that TB services are implemented vertically, isolated

from AIDS programmes. " They have different administrations, different

buildings, even different loyalties, " said Marta Darder, coordinator of

the Campaign for Access to Essential Medicines in South Africa.

MSF is experimenting with an alternative approach in its integrated

TB/AIDS clinics, like the one run by van Cutsem, where seven out of 10 TB

patients are HIV positive.

" We are trying to break the wall between the two services by integrating

the teams, " said van Cutsem. " It's not an easy process, but it is much

better for the patients. "

With the integrated services there is one entry point, one monitoring

system and one-stop care, instead of the patient having to queue twice in

different places, with additional transport and time costs.

Recognising the problem, WHO and the Stop TB Partnership established the

TB/HIV Working Group to coordinate the global response to the twin

epidemics and strengthen collaboration between TB and AIDS programmes.

" These activities will ensure the survival and improved quality of life of

HIV-infected TB patients but are not implemented by many affected

countries, " said Dr Nunn, coordinator of Stop TB's Unit for TB/HIV

and Drug Resistance at WHO's Geneva headquarters.

The basic problems of DOTS, says the MSF study, is that it built on old,

tried and tested technologies instead of developing more effective

diagnostics, vaccines and drugs. AIDS magnifies the limitation of DOTS -

but it also offers an opportunity to rethink the global TB strategy, the

report concludes.

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