This week, ahead of the G20 summit in Hamburg, Médecins Sans Frontières (MSF) and the Stop TB Partnership released the third edition of their report 'Out of Step,' based on surveys of TB policies and practices in 29 countries. The survey shows that many countries are out of sync with global policies.
Even though we have tools and interventions to fight TB, the sad reality is that over 10.4 million people develop this disease every year, and nearly 1.8 million people die from a curable infection. The report by MSF and Stop TB Partnership, third in the series (first two were published in 2014 and 2015), provides a vital clue as to why TB continues to wreak havoc in many low and middle income countries. Put simply, many countries are not implementing tools and policies that are known to be effective and life saving! This failure has devastating consequences for patients and their families.
Let us begin with diagnosis, the first critical step in curing TB. We know rapid molecular tests such as Xpert MTB/RIF are highly accurate and can also simultaneously detect multidrug-resistance (MDR). WHO has strongly endorsed the use of this novel tool. But does this translate to implementation on the ground? The Out of Step report shows that in the 29 countries surveyed, 52 per cent (15) have adopted a policy of 'Xpert for all' and 47 per cent (7/15) of them have widely implemented the test. The rest are using Xpert only in selected groups of patients, while still relying heavily on smear microscopy – a century-old test that misses nearly half of all TB patients, and a provides no information on drug-resistance.
Late or inadequate diagnosis can delay life saving treatment, and put patients at risk of drug-resistance. One of us (DC) has survived drug-resistant TB, after six years of drug therapy with horrible side effects, with much of my left lung removed. In the early stages of my treatment, my doctors kept changing my treatment without testing me for drug-resistance. That cost me dearly. We simply cannot use toxic drugs without knowing whether they will work or not. All patients with TB have a right to know whether their treatment will work for them or not.
What about new TB drugs that have shown a lot of promise for patients with drug-resistant TB? According to the report, 79 per cent of countries surveyed include the newer drug bedaquiline in their national guidelines, and 62 per cent include delamanid in their guidelines; but globally, only five per cent of people who could have benefitted had access to these drugs in 2016.
Drug-resistant is a major concern in many countries, and patients often have to take two years of toxic pill combinations to deal with drug-resistance. In 2016, WHO endorsed the use of a shorter MDR drug regimen which can be given for nine months. The Out of Step report shows that only 13 of 29 countries (45 per cent) recommend these new shorter treatments in their guidelines. And none had made them widely available at the time of the survey.
As a MDR-TB survivor, I would have greatly appreciated new TB drugs and shorter regimens. Now that they are available, I cannot understand the slow pace of uptake by countries. Time is of essence - we need to remember that 1.8 million patients are running out of time and succumbing to TB each year!Deepti Chavan
Nearly 25 per cent of the world's population is infected by TB in its latent form. Preventive therapy can stop people with latent TB infection from developing active TB disease. While all of the countries surveyed provide it to the most vulnerable groups (child contacts of adult TB patients, and HIV-infected individuals), 31 per cent (9) of these countries have not implemented it widely. Only four countries provide preventive therapy to other high-risk populations that will benefit from such therapy.
Why do countries lag behind in offering effective interventions to their TB patients? Why are we always settling for less in TB, while those working in HIV have consistently raised their game? As we have pointed out elsewhere, there are many barriers to adoption and scale-up of new tools and policies: lack of adequate funding to national TB programs, regulatory hurdles, high cost of tools, bureaucratic apathy, and a low priority given to public health, in general.
India is an excellent example. Although India accounts for nearly 27 per cent of the world's 10.4 million new TB cases, and 29 per cent of the 1.8 million TB deaths globally, TB has received limited funding for decades. In fact, health itself has been a low priority for the country. Not surprisingly, the Out of Step report shows that India is yet to widely scale-up tools such as Xpert MTB/RIF, bedaquiline, and delamanid. India is yet to implement WHO policies on nine-month MDR shorter regimen and latent TB therapy for high-risk populations. Even the daily drug regimen for drug-sensitive TB is yet to be implemented across the entire country, and a desperate patient had to appeal to the court to get access to new, potentially life saving medicines.
The first step in fixing any problem is to acknowledge that there is a problem. The Out of Step report tells us what the problem is. It is wake-up call for the global health community, and underscores the desperate need for political will and adequate funding to tackle TB. All of us, patients, civil society, doctors, researchers, and TB controllers, should join the Step Up for TB campaign launched by MSF and the Stop TB Partnership and urge our governments to raise their ambition, and bring their TB policies and practices in line with global recommendations. It is time to stop settling for less!
Deepti Chavan, a survivor of MDR TB, now actively works towards creating awareness about TB prevention so that others do not suffer the way she did. Deepti was forced to drop out of her engineering degree when her health deteriorated. Today, she regularly counsels people with TB and speaks about her experiences on radio, print and TV to inspire patients to keep fighting. Her husband, Neeraj Musale, has been a big support in her battle against TB and encourages her to fight for this cause. @deepticomesback
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