TB runs rampant: A one-sided war

The global response to help countries scale up treatment of multidrug-resistant tuberculosis (MDR-TB) is underfunded and ineffective, according to a new report released last week by Médecins sans Frontières, Partners in Health and the Treatment Action Group.

In the past 10 years there have been an estimated five million new cases of multidrug-resistant TB and one-and-a-half million lives have been lost to this curable disease.

According to the World Health Organisation (WHO), less than 1% of the world’s drug-resistant TB patients have been enrolled in programmes that provide internationally quality-assured treatment.

The report identifies why efforts and progress to scale up treatment for multidrug-resistant TB have been ineffective. Unpredictable and expensive drug supplies were contributing factors.
One patient’s treatment for drug-resistant TB (DR-TB) can cost as much as R62 000, nearly 475 times more than a R130 treatment course for drug-sensitive TB. Alarmingly, the price of certain key second-line anti-TB drugs, most of which are off-patent and many are more than 50 years old, has increased in the past 10 years as some manufacturers put an end to subsidies that have kept prices lower.

The report also found that countries were prone to drug shortages and stock-outs-with serious consequences for patients. At an international level, there have also been a number of cases of global shortages and stock-outs of essential DR-TB drugs.

“We found that a lack of urgency and commitment from governments is a major stumbling block”, said Javid Syed, TB/HIV project director at the Treatment Action Group. “Many affected governments appear to be in no hurry to address the serious treatment needs of this devastating disease and this is impeding efforts to identify new MDR-TB cases. Donors are not making TB a priority and almost all of the major donors we contacted were unable to tell us how much of their funding was directed at DR-TB diagnosis and treatment. Besides funding, many countries will need global and regional support to build their capacity to diagnose and treat MDR-TB.”

“There are just too many barriers to scale up at the country level, such as the high price of second-line drugs,” said KJ Seung, clinical manager of Partners in Health Lesotho.

“Countries know they need to address MDR-TB, but with the high price of medication and lack of laboratory capacity they are often unable to scale up programmes. International support mechanisms need to be more efficient and effective to help address these barriers.”

According to the three organisations, the guidance and support given by international support mechanisms, such as the Green Light Committee (GLC), which monitors and assesses the progress of country multidrug-resistant TB treatment programmes; the Global Drug Facility (GDF), which supplies drugs to programmes approved by the Green Light Committee; and the Global Laboratory Initiative, which supports countries to set up new diagnostic services for TB, all fall short of providing what is needed. These mechanisms are hosted by the World Health Organisation.

The report findings show that the Green Light Committee and the Global Drug Facility were not able to complement efforts by national departments of health across the world appropriately. Only 0.6% of the five million new MDR-TB patients globally over the last decade were treated through GLC-supported programmes.

It also concluded that the Global Laboratory Initiative, though driven by laudable goals, was not transparent about what it had accomplished and was unable to provide data, making it impossible to evaluate its performance.

The Green Light Committee Initiative, designed to help countries gain technical support to scale up treatment of multidrug-resistant TB and access quality-assured drugs for it, needs to be closely monitored to see whether the organisation’s 20-month effort to reform itself will address key bottlenecks.

“The old GLC mechanism was no longer suited to help countries scale up treatment programmes,” said Tido von Schoen-Angerer, executive director of Médecins sans Frontières’s campaign for access to essential medicines. “The recent effort to reform the GLC has resulted in creating more committees, which I doubt will help countries and certainly do not address many of the bottlenecks countries face.

“Even as GLC and GDF undergo their transitions, interim markers of success need to be set up and their progress measured. Increasing funding is provided to these mechanisms, with very little evidence of their effectiveness.

“Donors, in particular, are well positioned to facilitate the transparent reporting of results from these support mechanisms in return for financial support. Donors need to make the scale-up of DR-TB diagnosis and treatment a clearly articulated priority and should provide information about total funding provided for DR-TB diagnosis and treatment, as well as disaggregated information about specific interventions within this category,” said Von Schoen-Angerer.

According to Médecins sans Frontières, untreated drug-resistant TB encourages the disease’s spread. But with insufficient numbers of patients on treatment, demand for drug-resistant TB drugs is low and the market for the development and production of the drugs remains unattractive. This creates a vicious cycle because limited drug supplies hinder the scaling up of drug-resistant TB treatment.

As demand stays low, not least for WHO quality-assured drugs, there is little incentive either for new producers to enter the market or for existing producers to invest in meeting WHO quality standards or to increase production capacity. Supply insecurity because of delivery delay or interruption means that programmes have been cautious rather than ambitious about the number of people they aim to treat a direct disincentive to increase treatment.

Low demand for drug-resistant TB drugs is caused also by the difficulties surrounding diagnosis—only 11% of 440 000 new multidrug-resistant TB cases were detected in 2009. Until recently it has taken up to three months to determine a patient’s precise drug-resistance profile. Diagnosis of TB is especially complicated in both children and people living with HIV/Aids.

But a new diagnostic tool based on molecular technology could help break open the vicious circle by dramatically shortening the time it takes to determine whether someone has TB to 90 minutes.

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