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New York Times, Septembere 20, 2004

Necessary Treatments for AIDS

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 months.

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 years.

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.

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