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“You are more invested in the DOTS model — which has failed [to contain] multidrug-resistant TB (MDR-TB) and which is now breeding extensively drug-resistant (XDR) TB — than you are in saving lives,” Mark Harrington, Executive Director for the Treatment Action Group (TAG) told TB (tuberculosis) experts attending a symposium held by the Stop TB Partnership of the World Health Organization (WHO). The symposium occurred a day before the 37th Union World Conference on Lung Health, which took place in Paris from November 1-4, 2006. Harrington challenged the TB experts to put the interests of people with TB first, and to act aggressively to put the necessary infrastructure in place to diagnose MDR-TB and XDR-TB.

Shift to Community-Based Approach

Directly observed therapy (DOTS) is a public health-based approach to TB control which focuses primarily on preventing the spread of TB by screening for people with active infectious pulmonary TB (as detected by smear microscopy), and then engaging healthcare workers to directly observe the administration of treatment to the person with infectious TB until the infection is cured.

Activists have accused the DOTS approach of treating people with TB more like vectors of disease than human beings — stigmatizing them, and thereby greatly undermining any potential for empowerment of TB patients and the development of a TB activist community. Furthermore, many believe the model virtually ignores most people with HIV-related TB, who often have either extrapulmonary or smear-negative TB, because those conditions are generally non-infectious (though no less fatal), and people with multidrug-resistant TB (MDR-TB) because they were too difficult to treat. As a result, for years people with MDR-TB and smear-negative HIV-related TB were neglected and essentially left to die.

But in the face of the failure of the DOTS approach to contain TB in countries with a high burden of HIV, the TB world has in recent years been attempting to revamp its policies and engage the TB- and HIV-affected communities. With the assistance of HIV/AIDS activists, they have also adopted more of an activist approach towards getting the necessary funding to develop new tools to diagnose, prevent and treat TB. This new policy direction is laid out in the recent Global Plan to Stop TB 2006-2015.

However, according to a recent policy report from TAG (Tuberculosis Research & Development: A Critical Analysis), these efforts don’t go nearly far enough. Although the Global Plan estimates a funding need for $9 billion in research on new TB tools including new drugs, diagnostics and vaccines, according to the TAG analysis, the Global Plan did not budget for the basic science, infrastructure development, and operational research necessary to provide a foundation for and validate these new TB tools. “The Global Plan does not specifically call for greater investment in basic science, which underpins all discovery efforts, nor does it fully account for the operational research needed to integrate new tools into health care systems,” the authors wrote. TAG estimates that investment in these areas needs to increase at least five-fold to approximately $950 million per year.

Is the TB World Up for Handling the XDR-TB Crisis?

According to Harrington, the emerging crisis of extensively drug-resistant TB highlights some of the other shortcomings of the Global Plan — and the tepid response on the part of the TB research and treatment community in confronting MDR-TB over the years.

“Now the reason why I am saying to many of you that you really believe in DOTS and you don’t believe in saving the lives of people with MDR-TB is because it’s not in your Global Plan to treat 75% of the people who are going to get MDR-TB in the next ten years,” he said. “And it’s not in the Global Plan to scale up the labs to even do a good job with [smear microscopy]; and it’s not in the plan to scale up infection control; and it’s not in the plan to scale up to universal [drug sensitivity testing] and culture; and it’s not in the plan to put up enough money for research and development. So even though you guys all work in TB and you all think you are trying to save lives, some of you are addicted to the DOTS strategy — which is a public health strategy and is not a patient-centered strategy — and it condemns hundreds of thousands of people a year to death.”

Many resource-limited settings confronted by TB/HIV and the potential for high mortality from MDR-TB and XDR-TB lack the basic laboratory infrastructure to perform drug sensitivity testing, culture and diagnose TB in a timely manner.

To Harrington, this is particularly galling: “As an AIDS activist I’m here to tell you that this is unacceptable, and it’s a failure of leadership at all levels,” he said. “I want you all to become activists and radicals… and call for universal access to high quality first-line and second-line treatment and cure for everybody that gets TB — adult and child, MDR and drug susceptible, TB HIV-positive and TB HIV-negative. I think that universal access to all these TB interventions by 2010 is a non-negotiable demand, and you all need to go back and rewrite your Global Plan to get us to universal access by 2010. To do anything less is to let down the millions of people that you claim to serve and whose lives you’re being paid to save.”

Javid Syed, WHO Community Representative and TB/HIV Project Director for TAG put the issue somewhat more gently: “Our main goal has been to look at how we can apply some of the lessons learned in the HIV world and apply them to the TB world. One of our main messages is that the TB world is really humble in what it asks for, and it quite often never asks for what it needs. Part of our message is that we should really be more ambitious about asking for what we need.”

The original article appeared on, November 2, 2006.

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