On World TB Day, Dr. Jay Achar (@dr_jay_a) of Médecins Sans Frontières (@MSFSci) explains how, despite encouraging innovation in the fight to eradicate TB, progress could be stalled if TB actors become complacent
Over the last decade, the drug-resistant tuberculosis (TB) treatment landscape has shifted and a flurry of progress and innovation has emerged. The list is long: newer, more effective, less toxic, and shorter-duration drug regimens will be simpler for patients and health systems to use. Painful, resource-intensive injectable medications are being relegated to options of last-resort. Evolving global guidelines are prioritizing newer, more effective, and more tolerable drugs and are starting to promote patients’ involvement in their treatment choices. Innovative treatment delivery models can provide life-saving drugs closer to people’s homes. Research hopes to find better ways to treat difficult to reach populations like children, those in conflict environments, and people co-infected with HIV. And supportive volunteers are reducing TB stigma, increasing testing in communities, and helping patients complete treatment even when facing side-effects or financial hardships.
Ongoing technological advances also have great potential. Newer, non-sputum-based tests will improve the diagnosis of TB amongst those poorly served by existing diagnostics, while molecular drug resistance detection will shorten the time it takes for people to start effective treatment. New preventive regimens improve treatment completion rates, while treating DR-TB contacts may inform future clinical guidance. For the first time in decades, the drug development pipeline inspires optimism rather than dismay.
On the timeline to TB eradication, both the pace of change and the utility of new innovations seem to be accelerating. Yet TB has always been a terrible diagnosis to receive and remains so today.
Timeline to TB Elimination: Stuck in the Status Quo
TB is still the top infectious disease killer in the world, with 10 million sick in 2017 and nearly 1.5 million dying. On World TB Day 2019, it’s important to acknowledge how the current TB response remains antiquated: many continue to be hospitalized for months away from family, molecular diagnostic tests are out of reach for many, and access to the most effective drugs remains restricted. Civil society and patient groups are rarely consulted, and a TB diagnosis remains highly stigmatizing and fear-inducing, often resulting in delayed or incorrect diagnoses. Engagement with communities and higher risk groups (like those living with HIV, children, or pregnant women) is still inconsistent. Treatment regimens are complex, long, expensive, ineffective for up to half of recipients, and have debilitating side-effects that result in high levels of disengagement from care. For the most extensively resistant forms of TB, only around a quarter of those infected are expected to survive 5 years after being diagnosed.
Despite recent progress, we still seem far from seeing the end of one of the world’s oldest human pathogens.
TB at a Crossroads
Ultimately, the fight against TB stands at a crossroads. On one path, recent innovations are widely implemented and scaled up, and high-level political support, research, and strategy evolution continue as we start to gain the upper hand in the epidemic.
On the other path, hard-earned progress risks being wasted if TB funding continues to stagnate, programs begin to atrophy or diminish, and the epidemic spreads silently out of control. There are worrying signs that this second path is looming large: Bi-lateral donors to low-and middle-income countries (LMIC) are emphasizing “shared responsibility” with local Ministries of Health (MoH), a noble goal that nevertheless fails without contingencies for patients whose MoHs are not willing or able to step up. Drug availability also suffers when national systems replace donor-funded “pooled drug procurement” structures, but are not yet equipped to obtain the same quality, price, or reliable supply of medications. The world’s most important TB funder, the Global Fund to fight AIDS, TB and Malaria (providing 69% of all TB programming dollars spent in LMIC), has asked donors for only a modest increase in funding when it is replenished in October of this year, yet donor countries’ financial commitments may still fall short of this request. It is notable that the overall replenished sum, even if combined with an (optimistic) 48% increase in TB spending by MoHs, will be insufficient to reach global TB prevalence and mortality targets.
This lack of funding is not just about dollars and cents. Funding stagnation will impact patient care, TB program implementation, and global control strategies. Scaling up new drugs and technologies in places where they are most needed may become impossible. In MSF settings, for example, we anticipate that our MoH partners may hesitate to use newer, higher cost DR-TB drugs despite their greater effectiveness and safety. In a stagnant funding environment, proven community-based strategies, treatment support, and important work on TB policy and protocols may seem impossible to pay for when money for treatment is insufficient. Drugs that are not quality-assured may be used because of their lower cost, while tighter funding overall may lead to procurement problems and drug stockouts. Each of these events could substantially and significantly exacerbate an already raging epidemic of drug resistant TB.
Moving Forward, No Matter the Cost
Complacency at this key moment will be disastrous. Much work to find better TB drugs and tools has been done. If we do not build upon and widely apply these innovations as well as increase people’s ability to be diagnosed, treated, and cured, we will watch the TB elimination timeline perpetually lengthen as drug resistance draws success ever further away.
Jay Achar (@dr_jay_a) is an infectious diseases specialist currently working as a tuberculosis/HIV programme and research advisor within the Manson Unit of Médecins Sans Frontières (@MSFsci). Jay has extensive experience with MSF, supporting HIV/TB programmes across Central Asia and Africa.
Feature Image: MSF delivers patient-centered TB care that diagnoses and treats paediatric TB. Recent progress on child-friendly DRTB drugs and family-centered care are threatened if TB funding stagnates. Sabir Sabirov/MSF