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 Wednesday 03 October 2007
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PlusNews In-Depth

The New face of TB: Drug resistance and HIV

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SOUTH AFRICA: XDR outbreak raises questions about TB programme

Photo: Mujahid Safodien/PlusNews
New TB cases combined with the high HIV burden are straining the country's public health services to the limit
Since the recent outbreak of a virulent and virtually untreatable strain of tuberculosis (TB) in KwaZulu-Natal Province, the eyes of the TB world have been turned on South Africa.

Much of the debate has centred on the immediate problem of how best to contain the disease, but the question of how one of the most developed and well-resourced countries in Southern Africa became a breeding ground for extremely drug-resistant (XDR) TB has also been raised.

Some experts have blamed the growing problem of drug-resistant TB on the failure of TB control programmes to properly motivate and supervise patients to complete their 6-month course of TB medication.

South Africa's national TB cure rate is around 50 percent, way below the target of 85 percent recommended by the World Health Organisation (WHO).

Patients who develop multidrug-resistant (MDR) TB have a less than 50 percent chance of being cured, with about 20 percent failing to complete the two years of treatment. According to Dr Karin Weyer, director for TB research at South Africa's Medical Research Council, these high treatment failure rates are the "ideal recipe" for generating XDR-TB.

A number of meetings and consultations with WHO experts followed the outbreak in KwaZulu-Natal but, according to Weyer, little has happened on the ground. Most of South Africa's nine provinces have failed to systematically screen all MDR-TB patients for XDR, or carry out surveys to assess the geographical spread of the most dangerous form of TB.

Dr Lindiwe Mvusi, TB director at the national Department of Health, blamed the limited capacity of the country's laboratory services, but Weyer had a different explanation.

"TB has always been an epidemic of complacency and we see the same complacency now with XDR-TB," she said. "It has created urgency at the global level, but we're still talking about a TB crisis plan; we haven't seen it implemented."

Technology lags behind

Mario Raviglione, head of the WHO's 'Stop TB' Department, recently pointed out that XDR-TB was more than likely present in other countries in the region that simply lacked the laboratory capacity to detect it.

''TB has always been an epidemic of complacency and we see the same complacency now with XDR-TB''
On the other hand, Weyer noted that South Africa had the capacity both to detect and manage XDR. "Many other countries face financial constraints. In South Africa we have enough money to do a good job on TB control, we have a good infrastructure relative to other countries in Africa, and we have more laboratory capacity than the whole of Africa put together."

The currently available technology takes up to six weeks to confirm MDR and XDR cases, but two new rapid diagnostic tests about to begin trials in South Africa and four other African countries could reduce that time to one or two days.

Meanwhile, a new drug for treating XDR TB is still 10 years away. "That creates the obvious dilemma that we'll be rapidly identifying cases and then having very limited treatment options," said Weyer.

HIV adds to the burden

Dr Eric Goemaere, of the international medical relief organisation, Medecins San Frontieres (MSF), argues that the root of the drug-resistant TB problem in South Africa lies with the failure of TB programmes to adapt to an epidemic of TB-HIV co-infection.

An estimated 60 percent of TB patients in South Africa are HIV-positive but, according to Goemaere, the response has largely been "business as usual".

Of the 1.6 million people globally who died of TB in 2005, 195,000 of them were HIV infected
He noted that while South Africa's TB caseload has doubled in the past 10 years as a result of HIV, nurses at the local clinic level have not been properly equipped to deal with the increased numbers of patients, or the diagnosis and treatment complications that co-infection brings.

In theory, health workers are receiving training in how to manage co-infected patients, and TB and HIV/AIDS programmes are moving towards greater integration but, Goemaere said, implementation has been extremely slow. "At the moment, integration is a nice word but it's not happening," Weyer agreed.

At a clinic in Potchefstroom, a former mining town in South Africa's North West Province, about 120km from Johannesburg, TB and HIV/AIDS services have been combined into one unit consisting of a small consultation room and an even smaller waiting area, where mothers with babies sit beside painfully thin young men.

"It's overcrowded and [there are] not enough staff; it's really terrible, but this is typical," commented Ann Prellor, the province's TB coordinator. "If they could triple the size of this clinic as well as the staff, it would still be busy."

An appointment system is supposed to limit the number of patients passing through the unit to 10 a day, but many arrive without an appointment. Sister Magdeline Matthews and her two nursing assistants often see more than 30 patients a day.

Last year they diagnosed 144 new TB cases, of which 66 percent were co-infected with HIV. Based on the province's track record for TB treatment, 54 percent of those patients will be cured, 9 percent will fail to finish their 6-month course of drugs, 7 percent will die and many others will simply be lost from the system because they are untraceable.

"We have lots of people from the farms, and because they don't have money and transport to come to the clinic, they default and it's difficult to follow them," said Matthews.

DOTS failure

The standard for TB treatment recommended by the WHO is Directly Observed Short-Course Treatment (DOTS), in which volunteers monitor TB patients while they take their daily medication. The health department reports 100 percent DOTS coverage but the Medical Research Council's Weyer described implementation as "100 percent a failure," mainly due to human resource constraints.

While Weyer believes that DOTS could still be effective if the health sector worked in greater cooperation with the nongovernmental organisation (NGO) and private sectors, Goemaere argues that the DOTS model has become redundant in the HIV/AIDS era.

Photo: World Lung Foundation
"Most patients who are co-infected are trusted to take ARVs [antiretroviral drugs] in a responsible manner," said MSF's Goemaere. "The same patient then goes across the road to the TB clinic and is told they're not responsible enough to take TB treatment - it doesn't make any sense."

At MSF's integrated TB and HIV clinic in the Western Cape township of Khayelitsha, on the outskirts of Cape Town, TB patients receive two weeks of intensive education before starting treatment and regular counselling afterwards. The result has been a cure rate of 72 percent.

At the Potchefstroom clinic the majority of patients choose to "self-supervise" and, of the 25 percent who do have DOTS supporters, most prefer family members over volunteers, who are in short supply.

"We have some NGOs that support us," explained provincial TB coordinator Prellor, "but volunteers often demand stipends, and who do you give them to and who not? It's not sustainable."

Matthews admitted that she and her staff lacked the time to give patients more than a 30-minute counselling session at the onset of treatment. "It's actually after about two months [of treatment], when you start feeling so much better, that you need the reinforcement," commented Prellor.

According to Bea Pretorius, the Potchefstroom clinic's manager, the attitude of nurses and their willingness to enter into a long-term relationship with TB patients also play a major role in whether or not patients complete treatment.

"TB is hard work, both emotionally and in terms of the administration," she said. "If you're not up to it, you're not going to do it as it should be done."

The way forward

Prellor and Pretorius appear unfazed by the XDR threat and insist that staff have been following correct protocols for screening MDR suspects for years.

"We had our first XDR case in this province in 2002, so it wasn't a new thing that bombed down on us," said Prellor.

Last year the Health Department launched a TB crisis plan aimed at improving cure rates in districts with the highest TB caseloads. The health department's TB director, Mvusi, told IRIN/PlusNews that an XDR response plan had also been finalised and was being implemented, but Weyer and Goemaere were still waiting to see such a plan.

"Now we've decided to develop a district plan, because if we wait the problem is going to get worse," said Goemaere.

Weyer also feels that the window of opportunity is closing quickly: "It's still a problem that is small enough to contain and manage properly but we need to be doing something now. If we don't, WHO has warned we face the possibility of the drug-susceptible TB epidemic being replaced by a drug-resistant TB epidemic, which will take us back to the Middle Ages - before we had any drugs to treat infectious diseases."


This report is part of a PlusNews In-depth: 'The New face of TB: Drug Resistance and HIV'

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