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12 Sep 2018

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

In 1966, we junior interns at Sydney’s Royal North Shore Hospital were accommodated at Lanceley Cottage. It lay just beyond the thoracic unit, where patients with active TB were treated on the top floor. Their medication included PAS (para-aminosalicylic acid) – not liked because of its volume or its aspirin-like taste. Walking to the main hospital each morning, we had to dodge the PAS ‘rain’ from disgruntled patients as they tipped their daily dose over the balcony. Compliance with treatment, even in hospital, has been a problem for as long as effective chemotherapy has been available.

Human tuberculosis has been around for at least 5,000 and perhaps 9,000 years. The mycobacterium shows great resilience. If it had been listed on the stock exchange, it would have yielded a high dividend with few interruptions. Most recently, it has settled into the communities where HIV/AIDS is prevalent, adding to the burden of misery.

Nor is it limited to humans. As Wikipedia points out: “Seals and sea lions that bred on African beaches are believed to have acquired the disease and carried it across the Atlantic to South America.”

Like HIV, TB’s victims are often young, triggering art and poetry to lament the loss (see the photo above of a painting by Cristobal Rojas, himself suffering from TB at the time of this painting).

On September 26 this year, a high-level meeting of the UN will convene in New York with the theme "United to end tuberculosis: an urgent global response to a global epidemic". High-level meetings attract heads of state and are rare events for health. Previous meetings have considered HIV (2011) and non-communicable disease (2014). So this is big ticket.

As with most top-drawer international diplomatic events, the UN meeting has been preceded by much hammering out of the agenda. For example, In November last year, the Moscow Declaration to End Tuberculosis was agreed to by 75 ministers of health. Strong on rhetoric, but also substantial, it aimed to promote multi-sectoral action (never forget that TB thrives in impoverished societies), “track progress, and build accountability – signalling a long overdue global commitment to stop the death and suffering caused by this ancient killer”.

The WHO provides the following facts about TB:

  1. In 2016, 10.4 million people became ill, and 1.7 million died from it (including 400,000 among people with HIV). More than 95 per cent of deaths occur in low- and middle-income countries;
  2. Seven countries account for 64 per cent of the total cases, with India leading the count, followed by Indonesia, China, Philippines, Pakistan, Nigeria and South Africa;
  3. In 2016, an estimated 1 million children became ill and 250,000 children died (including children with HIV-associated TB); and
  4. It’s a leading killer of HIV-positive people: in 2016, 40 per cent of HIV deaths were due to TB. HIV increases the risk of TB 20-30 fold.

In some places, TB has become resistant to isoniazid and rifampicin, two major treatments, and to other drugs as well. Fortunately, new diagnostic methods can rapidly detect multi-drug resistant (MDR) TB, enabling shorter and probably more efficacious treatment regimens. The magnitude of MDR-TB is seen in the claim that only a quarter of infected people are currently detected and fewer are adequately treated.

Earlier this month, the WHO announced changes to drug-resistant treatment regimens.

Using available high-quality evidence, a new priority ranking of the medications has been proposed, such that treatment is based on a careful balance between expected benefits and harms.

The second important change is a fully oral regimen as one of the preferred treatments for MDR-TB, with injectable agents to be replaced by more potent alternatives such as bedaquiline (the first-ever medicine to be developed specifically for MDR-TB).

“The treatment landscape for patients with MDR-TB will be dramatically transformed for the better,” said Dr Soumya Swaminathan, WHO Deputy Director-General for Programmes.

“WHO has moved forward in rapidly reviewing the evidence and communicating the changes needed to improve the chances of survival of MDR-TB patients world-wide. Political momentum now needs to urgently accelerate, if the global crisis of MDR-TB is to be contained.”

While TB is yielding to effective new treatments such that it is possible to envision a day when it has been eliminated, no such confidence can be applied to HIV. 

The August 2018 report from UNAIDS, Miles to Go, http://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf draws attention to stalling in the program to reduce the incidence and prevalence of HIV and AIDS.  It speaks critically of ‘complacency’: in 2017, 180,000 children became infected. One million people die of HIV/AIDS related illnesses each year. But we must balance these disturbing figures against a remarkable achievement with treatment: 22 million people are on anti-HIV drugs. 

It is at the intersection of HIV and TB that urgent action is needed. As Michel Sidibé, who comes from Mali and serves as Executive Director of UNAIDS, the Joint United Nations Programme on HIV/AIDS, and as Under-Secretary-General of the United Nations, writes in the Foreword to the UNAIDS report,

“The upcoming United Nations High-Level Meeting on Tuberculosis is a huge opportunity to bring AIDS out of isolation and push for the integration of HIV and tuberculosis services. There have been major gains in treating and diagnosing HIV among people with tuberculosis, but still, decades into the HIV epidemic, three in five people starting HIV treatment are not screened, tested or treated for tuberculosis, the biggest killer of people living with HIV.” (Mr Sidibe’s attention has recently been rather distracted by sexual harassment concerns.)

So, with TB and HIV we have achieved much – not only in Australia, where we are blessed with the necessary prosperity to detect and treat, but also globally and in poorer countries. 

To bridge the remaining gaps, we require money, committed people, political enthusiasm and broad vision. Several Australian doctors and nurses are making major contributions to the control of TB and HIV throughout Asia and elsewhere. Let’s salute them while realising there is space for more to join them.

 

Further background: BMJ, Revisiting the timetable of tuberculosis https://www.bmj.com/content/362/bmj.k2738


Published: 12 Sep 2018