Dr. John Bartlett’s presentation last week was a great introduction to Dr. Carol Hamilton’s TB lecture today, emphasizing challenges of TB/HIV co-infections and growing drug-resistance, both causing individual and structural (e.g. systemic) barriers to global TB control. Although TB is a major challenge in India and China (accounting for 35% of the global burden in just those two countries alone), a lot of Dr. Hamilton’s lecture focused on the concentration of TB/HIV co-infection in sub-Saharan Africa as well as drug-resistant TB. Brittney just returned from five weeks working in multi-drug resistant tuberculosis (MDR-TB) hospitals in South Africa (in the KwaZulu-Natal and Eastern Cape provinces) where 70% of MDR-TB patients are co-infected with HIV. We think Dr. Hamilton’s points about current TB treatment being problematic were well stated and cannot be under scored enough – especially within certain populations such as children or those co-infected with HIV. The treatment burden can be immense; for those infected with MDR-TB daily treatment consists of approximately 15-20 pills per day along with a daily injection for up to six months during the intensive phase of treatment.
For individuals co-infected with HIV, pill burden and drug interactions may be increased. Despite this, initiation of antiretroviral therapy (ART) is recommended in all patients co-infected. Attached is a recent meta-analysis measuring “The Effect of Early Initiation of Antiretroviral Therapy in TB/HIV Coinfected Patients: A Systematic Review and Meta-Analysis” which assessed 2,272 study participants from 6 trials where early ART initiation (2-4 weeks versus 8-12 weeks) was conclusively found to reduce all-cause mortality in TB/HIV co-infected patients (Abay, et al. 2015). This evidence strengthens many national TB control program guidelines, although implementation of recommendations surely will be a challenge. In settings where lack of reliable supply chains exist, access to care and poverty are daily concerns, and poor diagnostics and/or lack of provider awareness of proper protocols is common; dual therapy for TB and HIV is, and will continue to be, challenging. Translating this dilemma to the pediatric population only adds complexity. The photo (from the TB Alliance) below illustrates just how demanding of a regimen we ask patients to accept.
As a final thought, story telling is another
way in which to raise awareness to global health challenges in a unique
way. In order to get grants funded or
manuscripts published we need decent data.
We all know that. However; the
human connection and the stories behind the numbers are what call most of us
into this field, and what bring us satisfaction after arduous days in the
field, or sleepless nights writing, reading, and interpreting our data. These are a few more stories worth
highlighting the impact and burden of TB in addition to Thembi Jakiwe’s story
of strength we shared earlier.
- Dalene von Delft – a physician from South Africa tells her battle with MDR-TB
- Dr. Lucica Ditiu (Executive Secretary of the Stop TB Partnership) talks about the stigmatizing language surrounding TB.
- Phumeza Tisile: HearNo Evil – a South African woman who survived XDR yet suffers from permanent hearing loss due to kanamycin (causing severe ototoxicity) discusses her journey through treatment and life after TB.
- Thato Mosidi - a physician in South Africa tells her story of being diagnosed with XDR and the isolation it caused her from her husband and 3-year-old daughter.
