[FoRK] (no subject)

Rohit Khare Rohit at ICS.uci.edu
Mon Sep 20 14:36:52 PDT 2004

There are few more cost-effective ways to reduce human suffering than 
clean water. Even "old" drugs are up there, too... sigh. Rohit

September 19, 2004
Necessary Treatments

No one dies of AIDS. This is not denialism. The truth is that the AIDS 
virus does not kill you -- it simply degrades your immune system so 
that something else does. Quite often that something is tuberculosis. 
TB is the leading AIDS-related killer, perhaps responsible for half of 
all AIDS-related deaths. In some parts of Africa, 75 percent of people 
with H.I.V. also have TB.

  Tuberculosis is a wasting disease, usually of the lungs, and until the 
discovery of antibiotics, it affected millions of people even in 
wealthy nations. Today, more people die of it than ever -- about two 
million per year -- and in sub-Saharan Africa, cases are rising by 6 
percent a year. The reason for the TB explosion is the spread of AIDS: 
having H.I.V. makes an individual vastly more susceptible to 
tuberculosis. In turn, TB has brought an especially early death to many 
AIDS victims. An H.I.V.-positive patient who contracts TB and does not 
receive treatment has a 90 to 95 percent chance of dying within a few 

  TB has played a part in making AIDS the plague it is today. But the 
horrifying collision of these two diseases also offers a double 
opportunity to save lives. The obstacle is that TB is still regarded as 
a relic. Granting tuberculosis the respect it deserves offers a 
crucial, and unheralded, way of delivering hope to AIDS sufferers.

  In the long term, antiretroviral therapy must be made available to all 
who need it. But millions in the third world will die waiting. For 
many, curing their TB with a regimen of inexpensive pills or injections 
could allow them to live years longer. The very universality of TB 
makes it ripe for intervention. Fully one-third of the world's 
population is infected with TB. In the vast majority of people, the 
infection is latent. But when an individual becomes H.I.V.-positive, 
his or her immune system is less able to ward off the onset of active 
TB. So millions will suffer from TB early in the course of AIDS -- 
sometimes years before they would have been stricken by another deadly 
infection. Curing this early TB can buy people years of health while 
they wait for antiretrovirals.

  How many years? One answer comes from Cange, a village in central 
Haiti, where the Boston-based group Partners in Health runs a medical 
complex. In 2001, doctors from the organization published a paper about 
a group of TB patients they treated in 1994. They found that nearly all 
of the TB patients who also had H.I.V. were still alive in 2001 and 
that only 5 of the 27 they could track down needed to start 
antiretroviral therapy.

  Imagine a cancer drug that could bring patients seven more years of 
caring for their children, of working -- of living. It would be 
considered a huge success. A drug that performed this feat for $11, in 
AIDS patients, without antiretrovirals, would be called a miracle.

  In contrast to antiretrovirals, TB pills have the enormous advantage 
of being cheap: even though TB patients must take medicine for six to 
eight months, the complete course costs about $11. And the course is 
effective. Even the poorest countries can cure more than 90 percent of 
the TB cases they treat -- if they employ a relatively new strategy.

  That strategy is known as DOTS (Directly-Observed Treatment, 
Short-Course), and it is one of the world's most cost-effective health 
interventions. Malawi and other African countries pioneered the program 
in the 1980's, and in 1995 the World Health Organization introduced it 
globally. It is used far too little -- in Africa, two-thirds of those 
with both H.I.V. and TB live in places where DOTS still hasn't arrived. 
But where it is used, it works. Peru and Vietnam cure more than 90 
percent of their cases. Half of China uses it, and rates of cure there 
approach 96 percent for new cases.

  A successful DOTS program requires a political commitment to sustained 
TB control. To prevent more lethal strains of the disease from 
spreading, a country must ensure an uninterrupted supply of drugs. 
Clinics must have a simple, cheap method of diagnosis and must track 
and report patients' progress. They must also find ways to ensure that 
patients take their medicine every day for at least the first two 
months. In many countries, the patient chooses a family member for this 
job. In Haiti, Partners in Health trains and pays largely illiterate 
community members as accompagnateurs. They visit three or four families 
a day, watch patients swallow pills and provide moral support.

  Now suppose you are an African AIDS official struggling with questions 
like: How can I identify the sick and persuade them to come for 
treatment? How can I get them a steady supply of pills? How can I help 
them to take their medicine, day after day after day? If your country 
has DOTS, you already know the answers. You have a system that reliably 
gets drugs to patients, teaches them to take pills regularly and tracks 
their progress. And in many places, the patients with TB are 
essentially the same people who have H.I.V. Doctors Without Borders has 
a pilot clinic in Khayelitsha, a slum outside Cape Town, South Africa, 
that combines TB and AIDS services. It started as separate next-door 
clinics, says Eric Goemaere, who runs the program, but doctors decided 
to merge the clinics when they noticed that patients were going out one 
door and in the other.

  The fact that tuberculosis clinics are filled with H.I.V. sufferers 
should offer a way to solve one of the most vexing problems in both the 
prevention and treatment of AIDS -- finding the sick and getting them 
testing and counseling. Yet less than 1 percent of TB patients 
worldwide get AIDS testing.

  Why aren't more places adopting DOTS, testing TB patients and using 
their TB programs as models for treating AIDS? In large part, it's 
because TB is still invisible. The Global Fund to Fight AIDS, 
Tuberculosis and Malaria devoted only about 10 percent of its last 
round of grants to fighting TB. Research is so neglected that there 
have been no new drugs developed specifically for TB in the last 30 

  At July's international AIDS conference in Bangkok, Nelson Mandela 
talked about the tuberculosis he suffered from in prison and the 
world's desperate need to fight the disease. ''TB remains ignored,'' 
Mandela said. One reason is that he is practically the world's only 
famous TB patient since the Bronte sisters. It's a disease of the 
slums, of the poor and of prisoners. AIDS, by contrast, affects the 
rich as well. The sons of African presidents get AIDS. But they don't 
get TB.

  And Mandela merely used to have TB. No one used to have AIDS, which is 
treatable but incurable. AIDS activists -- without whom there would be 
no affordable AIDS treatment anywhere -- are largely people who 
identify themselves as living with AIDS. TB has no citizen-activists -- 
''People go quiet as soon as they are cured,'' says Alasdair Reid, who 
works on both diseases at the W.H.O. There are doctors who care 
passionately about TB, but they have been working in a ghetto. The 
world needs to join their battle -- both to stop a tuberculosis 
explosion and to save lives in the fight against AIDS.

  Tina Rosenberg writes editorials for The New York Times. Her last 
article for the magazine was about DDT.

More information about the FoRK mailing list