MSF Response to New WHO TB Treatment and Diagnostic Recommendations

Bithin Das

The World Health Organization has just recommended that countries move toward shorter treatment regimens for some people with drug-resistant tuberculosis (DR-TB), including people co-infected with HIV, children, and people with simple MDR-TB who have not been treated before or and have no known resistance to any of the drugs in the regimen. This recommendation comes following results from a number of large observation cohort studies using the shortened regimen.

Current DR-TB treatments usually run for 24 months and cause significant side effects; shortened regimens, which run as few as nine months, lessen disruption of patients’ lives and are easier for patients to tolerate and adhere to. International medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) began implementation of the shortened DR-TB treatment course in Uzbekistan in 2013 before expanding use of the regimen to Swaziland.

WHO is also recommending that people with confirmed rifampicin-resistant TB or multidrug-resistant TB be tested for extensively drug-resistant (XDR) and pre-XDR-TB using rapid molecular tests as the initial test, so that they can be offered treatment that is appropriate for them as soon as possible.

"The prospect of two years of TB treatment drives parents to hide their children from treatment, teenagers to abandon their ambitions, adults to decide between providing for their family or getting healthy, and the elderly to wish for death. The fear of relentless suffering due to side effects manages to outweigh any hope of cure or returning to a normal life. But when I tell patients that it’s only nine months of treatment, they respond, 'I can do that.'"

—Dr. David Lister, TB doctor for MSF in Uzbekistan and coordinator of the Nine-Month Short Course Regimen study

"WHO’s recommendation to move toward shorter treatment regimens for some people with drug-resistant tuberculosis (DR-TB) is a positive step and countries should waste no time in putting these recommendations into practice, where feasible and appropriate. Although this treatment isn’t suitable for all patients, MSF has seen positive outcomes using a nine-month regimen in Swaziland and Uzbekistan. Shorter regimens are easier for people to tolerate and more effective for some people with DR-TB, and significantly lower costs could enable TB programs to scale up treatment for many more people.

Ultimately, we can’t lose sight of the desperate need for completely new treatment regimens that work for all people with drug-resistant TB and that completely eliminate the old, toxic drugs still used in these shorter regimens, particularly the daily painful injections that people must endure.

We also welcome WHO’s recommendation that people should be diagnosed for pre-XDR or XDR-TB using the latest rapid molecular tests that can detect resistance to key second-line drugs; this is essential to ensure people who can benefit from a shorter treatment regimen can be quickly identified and started on the treatment that’s right for them.

The newly recommended tests are only suitable for use in central or regional-level laboratories, so in the long run, in order to get the most number of people diagnosed and on the correct treatment, we need rapid molecular diagnostic tests that can detect drug resistance and can be used in more peripheral settings.

These recommendations come ahead of expected new guidelines from WHO for the management of MDR-TB, but countries can already start to update their national treatment guidelines so people can benefit from the latest advances in MDR-TB care."

—Dr. Philipp du Cros, head of MSF’s Manson Unit and infectious disease specialist

Shanti (name changed) is a 38 year old semi-literate woman living in Mumbai. She has been living with HIV and multidrug resistant tuberculosis (MDR-TB) for the past 5 years. Before coming to MSF, she had undergone TB treatment three times, but, instead of improving, each time her health had worsened. She started her treatment for MDR-TB from MSF Mumbai Project in November, 2010. Given the side effects of anti-Tb medicines and high pill burden, she finds it difficult to continue with the treatment. â??If pill burden is reduced it would be a great relief. It seems that it is the medicines which have become my food now. There are more medicines in my stomach than food. The doctor says that when my weight will increase, the amount of medicines will decrease.â? Her husband provides her hope and courage to continue with the treatment . â??If my husband were not there I would have left the treatment long ago. It is his courage and faith that keeps me going.â?
Bithin Das