TB treatment needs as much focus as HIV

The week that has passed has been significant for the HIV/AIDS sector. It marked the 30th anniversary of the AIDS epidemic. World leaders gathered for a high level meeting on AIDS in New York and according to reports, a scientific blueprint for interventions that will enable us to save a million more lives by 2015 was unveiled.

The Stop TB Partnership released new scientific modelling at the meeting, which shows that with aggressive use of existing technology and tested interventions, TB-HIV deaths can be reduced by 80 per cent by 2015. In 2010 the Stop TB Partnership and UNAIDS set the joint goal of reducing by half the number of deaths among people living with HIV, compared to 2004 levels, between 2011 and 2015. With the new model, they have agreed to aim for the one million mark.

These are great achievements indeed, considering AIDS is only 30 years old. Let’s juxtapose that against TB, which is more that 125 years old. We have had practically no new developments on diagnosis, prevention or treatment. The most commonly used test for TB is still the smear microscopy which is as old as TB itself, and misses half of all cases. Prevention and treatment are not much better.

India’s directly observed treatment short-course (DOTS) programme has been counted among more successful ones in the world. But it will not be far-fetched to say that TB has come under a special spotlight largely by piggy-backing on HIV. Increasingly, TB is spoken of in the same breath as HIV as there is evidence to prove that TB is responsible for one in four AIDS-related deaths and therefore deserves more aggressive attention.

It’s time to pause and ask some questions here. What about those who are TB infected but not HIV positive? Who speaks for them? According to revised national tuberculosis control programme (RNTCP) India has around 1.8 million new cases of TB every year and and more than 3.7 lakh people die of TB every year in India How many of these are not HIV positive? What do health systems have in place to save these lives? These are questions that we desperately need to find answers to, even as we save a million precious lives that will suffer from the co-infections of HIV/TB. It is time to give TB the same attention that HIV gets, and take it to international forums with the same vigour and activism that HIV has managed to do.

Preparing the blueprint

The government is currently in the process of preparing the blueprint for the next phase of RNTCP phase 3 which will run from 2012-2017. Having crossed WHO’s targets of new case-detection of 70 per cent and treatment success rate of 85 per cent, the RNTCP is being expanded to ensure early detection and treatment of at least 90 per cent of estimated TB cases in the community.

Achieving the targets would mean better diagnosis as the currently used smear microscopy test is as old as TB itself and routinely misses half of all cases of TB.

Additionally, as Dr Madhukar Pai, associate professor, Dept of Epidemiology and Biostatistics, McGill University says: “Universal access, which is what is being aimed at, will mean that RNTCP alone cannot do it as more than 50 per cent of all TB patients in India are managed in the private sector. So, without a massive effort to engage private sector, universal access is impossible to reach. But RNTCP has done very little to engage the private sector so far.”

New diagnostic tools such as the GeneXpert hold great promise of being robust point-of-care (P-O-C) tools that are simple to use, and give immediate and reliable results. This means timely diagnosis and treatment. But there is a down side to this. With the depth and reach that a P-O-C such as GeneXpert will have, the number of patients diagnosed (both sensitive and MDR) is almost certainly going to increase dramatically. Once diagnosed, the patients must have access to treatment. This would mean a considerable increase in the need for and the cost of drugs (both first line and second line drugs) and also the infrastructure and systems to manage patients, particularly those with MDR TB.

Implementation of RNTCP 3 will involve huge resources and this brings us to the question of whether the government is committed to providing these funds. A back of the envelope calculation reveals it would involve tripling of the current annual budget of $65 million. Are we geared up for better diagnosis and the requirements thereafter? Do we have the funds required for this? Questions we must find answers to because a failure to do so means failing so many people who are entitled to health. Whether they are HIV positive or not.

(The writer specilises in health issues)