Tuberculosis: New Priorities, New Challenges

Doctors Without Borders/Médecins Sans Frontières (MSF) treated more than 25,000 people for tuberculosis (TB) in more than 100 projects last year. In half of these projects, tuberculosis treatment is part of MSF’s package of health-care services. In a quarter of projects, it is integrated into HIV/AIDS programs. The number of patients under treatment for multidrug-resistant TB (MDR-TB) is increasing: 580 in 2007, as against 260 in 2006.

Dr. Francis Varaine is coordinator of MSF’s tuberculosis working group. In this interview, he underlines the urgency of identifying new diagnostic means and treatments suited to MSF’s operating environment. He also discusses MSF's priorities for 2008.

Where exactly are we today in terms of tuberculosis diagnosis and treatment?

Kenya 2007 © Brendan Bannon

On the part of international institutions, we are today witnessing a sea-change as regards the stakes involved in the diagnosis and treatment of tuberculosis. The World Health Organization is beginning to recognize the need for new tools, as well as a greater amount of research.

At the MSF level, we must continue to show our results, and present the various approaches inherent in our programs, thereby demonstrating their effectiveness. But we need also to show their limits, due to the lack of suitable diagnostic and treatment tools.

As regards multidrug-resistant tuberculosis (MDR-TB), WHO estimates there are some 500,000 new cases every year, worldwide. A few years ago, we thought that this form of tuberculosis was limited to countries in the former-Soviet Union states. What we are now finding is that wherever we apply diagnostic means, we come across cases! With the present treatment for drug-resistant TB (which lasts two years and has many side effects), it is not realistic to imagine that all patients will be able to successfully complete such a regimen. Therefore a simpler and more effective treatment must be found as soon as possible.

So what exactly have been the main changes in MSF’s programs over the last year?

Well, we pursued our efforts to obtain generalized use of six-month treatment instead of eight-month regimen for simple—drug-sensitive—tuberculosis: this shorter course is more effective. We also opted for self-administered treatment; when we can combine it with sound patient follow-up.

Additionally, to increase our ability to diagnose MDR-TB, we upgraded our collaborative work with the laboratory of the Institute of Tropical Medicine at Antwerp. An MSF biologist and laboratory technician are producing cultures and antibiograms for all our projects, in particular for high-risk patients (those suffering from therapeutic failure or relapse).

Finally, what are MSF's priorities for 2008?

Thailand 2007 © Francesca Di Bonito

One priority is diagnosing tuberculosis in HIV patients: we are running a pilot project at Homa Bay in Kenya, where we have introduced cultures for all HIV patients where we suspect tuberculosis. This represents a large investment, in both financial and human terms. The employed technique gives a result in two weeks, instead of one month with the usual method. Such a time-saving technique is essential in this region of Kenya, where 80 percent of tuberculosis patients are co-infected with HIV.

More specifically, we want to improve diagnosis of drug-resistant tuberculosis in patients infected with HIV. Most often, these patients die before we can even confirm the diagnosis by tests (the waiting time for results from antibiograms is two to three months, using standard techniques). We therefore want to explore the feasibility of molecular techniques (PCR) in the field: these tests allow determination of resistance to rifampicin (a first-line anti-TB drug) and give results in less than 24 hours.

Another priority is to improve prevention and monitoring of nosocomial TB infections in our health-care structures. Our medical facilities must not themselves represent infection risks.