Why better TB care in Africa is in European interests

The recent outbreak of a lethal combination of HIV and TB in southern Africa has prompted Britain to pledge an extra US$ 3.15 million (£1.6 million) to the World Health Organization's Stop TB partnership.

The fact that all G8 countries admit the presence of TB strains that are extremely resistant to drugs (so-called Extensively Drug-Resistant TB or XDR-TB) brings home the WHO's unsettling message for World TB Day - ‘TB anywhere is TB everywhere'.

The slogan is backed by sobering statistics. More than 365 000 cases of TB were reported in the Europe in 2005, 10,000 more than for 2004. The figures for Europe are worrying enough, but XDR-TB in southern Africa is particularly threatening given the prevalence there of HIV infection. Although TB can infect anyone, people with HIV are at greater risk because they are less able to fight off infection. If, as is so often the case, they have undiagnosed TB, they will provide good conditions for the development of XDR-TB.

"Supporting patients to complete a full course of TB drugs is the key to preventing drug resistance developing". says John Walley, Professor in International Public Health and co-director of the DFID funded Communicable Disease Research Programme (COMDIS) based in Leeds.

XDR-TB develops when people infected with TB already resistant to first-line treatments fail to complete courses of second-line drug treatment. The WHO wants US$ 650 million per year for the next eight years to diagnose and treat more than 1.5 million people with drug-resistant TB but the success of its TB strategy relies on high levels of compliance of TB patients in taking daily medication over 6-8 months. A tall order when you consider how difficult it is to complete even a one-week course of antibiotics.

In this light Britain's response to the call for more funds may seem like a drop in the ocean but it is additional to long-term support of research such as COMDIS, which focuses on delivering better TB care in poorer countries. Such research has already helped the WHO to refine its TB strategy.

Professors John Walley and James Newell and their colleagues in Pakistan and Nepal have been researching ways of improving TB treatment within national TB programmes for many years. Their work, and research by other scientists in other countries, helped the WHO to move away from rigid directly observed treatment to stressing patient-friendly support.

Rather than requiring people to make expensive visits to clinics in order to be supervised while they take their TB medication, the emphasis is now on supporting the patients' families and communities in helping people with TB through their illness and long-term treatment.

The COMDIS model embeds research within national TB programmes and has proved hugely successful in Pakistan where new guidelines for TB health workers have been taken up nationwide. ‘We have contributed to a rise in recorded successful treatment rates from around 30 percent before the national scale-up of training to an average of 84 percent since', says Professor Walley.

COMDIS has taken the patient-friendly approach to TB care to Swaziland and has begun to apply this to anti-retroviral treatment for people with HIV. Community-based care is part of the package to improve adherence to treatment and avoid the development of resistance to TB and anti-retroviral drugs. ‘TB does not respect international borders', Professor Walley points out. ‘Controlling TB in these countries reduces the risk to us in the UK'.