TB experts, physician group, want change in TB treatment

The international medical aid organization Medecins sans Frontieres (MSF) on Tuesday backed calls for a new approach to the treatment of deadly drug-resistant tuberculosis, which is spreading rapidly among HIV patients in Sub-Saharan Africa. The changes should include an end to isolating TB patients in hospital wards for long periods of time - a practice MSF called counter-productive. Instead, they could be treated in their communities with individualized plans of treatment, MSF said. MSF was repeating its past calls for an end to the isolation ward treatment, a policy blamed for violent rioting by patients at a TB hospital in Gauteng province last week. "The reality is exploding in our faces," said Dr Eric Goemaere, MSF's head of mission in the sprawling Khayelitsha township outside Cape Town. He was referring to the high prevalence of drug-resistant TB in South Africa, the country with the largest number of HIV infections. TB is most frequent cause of death among the estimated 24.7 million people with HIV in Sub-Saharan Africa. Multi-drug-resistant TB (MDR-TB) occurs in patients that are resistant to the two most powerful first-line TB antibiotics. These patients have a less-than-50-per-cent chance of survival. Poor TB control programmes - including patients' not finishing their treatment - are usually blamed for the development of drug-resistance. But over the past two years, 30 per cent of more than 200 patients who developed drug-resistant TB in Khayelitsha had never had TB before, Goemaere noted. One in 10 MDR-TB patients goes on to develop resistance to two classes of second-line drugs, and becomes ill with a form of the disease called extensively-drug-resistant TB (XDR-TB), which is almost impossible to treat. Drug-resistant TB has been around since the 1940s but is aggravated in countries with a high HIV prevalence, according to Harvard Medical School's Carole Mitnick. The World Health Organization estimates the number of new drug- resistant TB cases at 450,000 each year. South Africa, where around one in five adults is HIV-positive, has about 6,000 new MDR-TB cases per year. MSF backed calls from Mitnick and other US experts in a report in Tuesday's edition of PLoS Medicine for MDR-TB patients to be included in clinical trials of new TB drugs. The magazine is available online as an open-source medical journal. "This is quite simply the best hope we have of getting improved medicines to patients with multi-drug-resistant TB faster," Goemaere said. "We cannot afford to wait." Until now donors had been focusing on the long-term goal of a complete new first-line treatment for both drug-resistant and normal TB, said Dr Tido von Schoen-Angerer, head of MSF's Access to Essential Medicines Campaign. This would likely take another decade or two. In the meantime, new trials were needed to achieve "some improvement in the desperate situation for MDR-TB treatment" by determining individualized treatment regimens for each patient. Contrary to the belief that isolation was necessary to prevent the spread of the infection, it was "probably the worst strategy", except in extreme cases, said Goemaere. A recent report in the British medical journal Lancet showed that the first outbreak of XDR-TB in South Africa in 2005/2006, which claimed the lives of 52 out of 53 patients, was driven by infections that occur in hospitals, he pointed out. Delays in diagnosis and obtaining a hospital bed also meant that MDR and XDR-TB patients had plenty of time to infect others before being isolated. In addition, patients were stigmatized because they spent two years in isolation. They suffered from side-effects such as deafness, kidney problems and severe nausea, from the medicine, leading to a total breakdown in understanding between doctors and patients, he said. MSF repeated its past calls for a strategy that would allow TB patients to remain within their community by developing infection control mechanisms, schooling people in cough etiquette and improving ventilation in clinics and minibus taxis. The run-up to the 38th Union World Conference on Lung Health in Cape Town on November 8-12 has been marked by a raft of position papers on TB and HIV/TB co-infection from health experts and NGOs. Around 3,000 delegates are expected at the conference, which will hear calls for a new, combined approach to the HIV/TB co-epidemic, including the need for a TB vaccine, new drugs and diagnostic tools. The experts writing in PLoS Medicine also called for improved funding for TB research, particularly new drug development, and towards building capacity for countries with a high TB burden to hold clinical trials.