Tuberculosis control: How can we do better?
In July 2004, Nelson Mandela called on the world to:
A delay of three to four months between symptoms starting and diagnosis is typical in Africa. These delays result in more advanced TB and a decline in the immune status of someone with AIDS. The causes for these delays are many and will include patient perceptions of the disease, stigma, difficulty in accessing health facilities and the poor quality of these health services. Research may be required to determine the major reasons for delay in particular settings, but all of these causes can be addressed.
A further cause for the delay is the poor quality of laboratory services. Research in Pakistan showed that a large number of smear-negative samples turned out to be positive when retested in a good-quality laboratory.
The role of adjunctive and preventive treatments
Experience from Malawi suggests that 40% of deaths from tuberculosis occur in the first month of treatment. It is possible that the use of empirical antibiotics (to control other bacterial infections) and corticosteroids (to control reactions to the TB medicines) may reduce this death toll. The use of cotrimoxazole has been recommended by UNAIDS on the basis of results of studies in Côte d’Ivoire. However, it is unclear how widely this recommendation has been implemented.
Isoniazid is recommended for the prevention of tuberculosis in people with HIV infection who are exposed to the disease. It is uncertain how widely this intervention is used but almost certainly there will be considerable room for improvement.
Monitoring the quality of clinical care
The quality of clinical care is crucial to successful TB control. While outcomes are regularly monitored (e.g. cure and default rates) there might be scope for a better assessment of process measures (e.g. attendance for treatment or response to adverse events).
Experience with directly observed therapy for tuberculosis (DOTS) in Africa has been highly variable. Treatment completion rates vary from 37% (low) in the Central African Republic to 78% (moderate) in Kenya and Tanzania. These rates are inadequate to effectively control the disease.
Cost implications
Tuberculosis control is a highly cost-effective way of extending the lives of people living with HIV. Using prices from the year 2000, TB treatment in Africa costs US$10 for a full six-month course of drugs – or in economist’s terms, less than US$75 per Disability Adjusted Life Year (DALY) gained. This is similar to the cost-effectiveness of Nevirapine or Zidovudine for the prevention of mother-to-child transmission of HIV, or of voluntary counselling and testing. It is much more cost-effective than other interventions such as home care programmes and antiretroviral therapy which both cost several hundred dollars per DALY gained.
Conclusions
It is extraordinary that TB control remains far from excellent in so many countries with a high prevalence of HIV. Worse still, it is astonishing that so many basic questions about TB treatment in the context of HIV are still unanswered, for example the role of adjuvant treatments. Despite the recent and welcome additional investment in TB programmes that has come from the Global Fund to fight AIDS, TB and Malaria, there remains scope to do much more. Without good TB control, many of those alive with HIV today may not be around by the time antiretroviral programmes become available.
HDN Key Correspondent
Email: correspondents@hdnet.org
(July 2004)
...recognise that we can’t fight AIDS unless we do much more to fight TB as well.Is there scope to improve tuberculosis control to extend the lives of people living with HIV? Some of the areas for improvement are considered below.
Interventions to reduce death rates in patients with tuberculosis in countries with high HIV prevalence:
- Reducing the delay between symptoms starting and diagnosis.
- Improving the diagnosis of smear-negative pulmonary tuberculosis and extra-pulmonary tuberculosis.
- Improving the treatment of smear negative tuberculosis.
- Research on the role of adjunctive treatments such as corticosteroids and antibiotic prophylaxis.
Monitoring the quality of clinical care. - Protecting healthcare workers from occupationally acquired tuberculosis.
- Protecting patients with AIDS from nosocomial tuberculosis (disease acquired in a health care facility).
A delay of three to four months between symptoms starting and diagnosis is typical in Africa. These delays result in more advanced TB and a decline in the immune status of someone with AIDS. The causes for these delays are many and will include patient perceptions of the disease, stigma, difficulty in accessing health facilities and the poor quality of these health services. Research may be required to determine the major reasons for delay in particular settings, but all of these causes can be addressed.
A further cause for the delay is the poor quality of laboratory services. Research in Pakistan showed that a large number of smear-negative samples turned out to be positive when retested in a good-quality laboratory.
The role of adjunctive and preventive treatments
Experience from Malawi suggests that 40% of deaths from tuberculosis occur in the first month of treatment. It is possible that the use of empirical antibiotics (to control other bacterial infections) and corticosteroids (to control reactions to the TB medicines) may reduce this death toll. The use of cotrimoxazole has been recommended by UNAIDS on the basis of results of studies in Côte d’Ivoire. However, it is unclear how widely this recommendation has been implemented.
Isoniazid is recommended for the prevention of tuberculosis in people with HIV infection who are exposed to the disease. It is uncertain how widely this intervention is used but almost certainly there will be considerable room for improvement.
Monitoring the quality of clinical care
The quality of clinical care is crucial to successful TB control. While outcomes are regularly monitored (e.g. cure and default rates) there might be scope for a better assessment of process measures (e.g. attendance for treatment or response to adverse events).
Experience with directly observed therapy for tuberculosis (DOTS) in Africa has been highly variable. Treatment completion rates vary from 37% (low) in the Central African Republic to 78% (moderate) in Kenya and Tanzania. These rates are inadequate to effectively control the disease.
Cost implications
Tuberculosis control is a highly cost-effective way of extending the lives of people living with HIV. Using prices from the year 2000, TB treatment in Africa costs US$10 for a full six-month course of drugs – or in economist’s terms, less than US$75 per Disability Adjusted Life Year (DALY) gained. This is similar to the cost-effectiveness of Nevirapine or Zidovudine for the prevention of mother-to-child transmission of HIV, or of voluntary counselling and testing. It is much more cost-effective than other interventions such as home care programmes and antiretroviral therapy which both cost several hundred dollars per DALY gained.
Conclusions
It is extraordinary that TB control remains far from excellent in so many countries with a high prevalence of HIV. Worse still, it is astonishing that so many basic questions about TB treatment in the context of HIV are still unanswered, for example the role of adjuvant treatments. Despite the recent and welcome additional investment in TB programmes that has come from the Global Fund to fight AIDS, TB and Malaria, there remains scope to do much more. Without good TB control, many of those alive with HIV today may not be around by the time antiretroviral programmes become available.
HDN Key Correspondent
Email: correspondents@hdnet.org
(July 2004)
posted by AIDS-Care-Watch at 7:12 pm
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