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
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
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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