A new era for tuberculosis?

Lancet Global Health
Oct 2018 Volume 6 Number 10 e1045-e1138

 A new era for tuberculosis?
The Lancet Global Health
In his keynote speech at this year’s Consortium of Universities for Global Health meeting in March, the former UN Secretary-General’s Special Envoy for HIV/AIDS in Africa, Stephen Lewis, delivered a blistering attack on the global response to tuberculosis. Citing it as one of three glaring examples of the consequences of inequalities worldwide (the others being climate change and conflict), he pointed to the 280-fold difference in tuberculosis incidence between Canadian Inuits and the non-Indigenous Canadian-born population, and to the “callous starvation” of funding for multidrug-resistant (MDR) disease in India despite the country’s massive burden.

Tuberculosis is the leading infectious killer globally and disproportionately affects disadvantaged populations—eg, homeless people, prisoners, migrants, people living with HIV. It therefore rightly maintains its place in the Sustainable Development Goals, whose guiding principle is to leave no one behind. The WHO End TB Strategy fleshes out these targets (ie, to reduce deaths by 95% and new cases by 90% between 2015 and 2035, and to ensure that no family suffers catastrophic expenses). Yet current progress is not commensurate with these ambitious aims. Stephen Lewis went so far as to call Narendra Modi’s assertion that India would eradicate tuberculosis by 2025 “nonsense”. This month sees an opportunity to change things for the better. On Sept 26, heads of state will gather in New York at the first UN High-Level Meeting (HLM) on tuberculosis with the aim of uniting to reboot progress and culminating in an “ambitious political declaration”. Will it make any difference?

UN HLMs are convened when there is a perceived need to engage all sectors in order to effect developmental, social, and economic change. Tuberculosis is indeed the epitome of a developmental, social, and economic problem. As Priya Shete and colleagues point out in a Comment published today, “Being poor increases the risk of falling sick with tuberculosis. Falling sick with tuberculosis also leads to impoverishment that can trigger a downward spiral of worsening health, ongoing tuberculosis transmission, and crippling medical expenses which further entrench poverty.” Referencing a modelling study published in The Lancet Global Health earlier this year, which estimated that expanding social protection coverage could reduce the global incidence of tuberculosis by 76% by 2035, Shete and colleagues call for integration of social protection with tuberculosis care within policies, programmes, and research.

Parallel efforts to highlight the importance of access to affordable tuberculosis drugs, particularly for MDR strains, have been ongoing ahead of the HLM. Earlier drafts of the political declaration—the key outcome document of the HLM—contained reference to the full use of flexibilities in intellectual property rules geared towards maximising access. Yet, under pressure from the USA and others, the final draft saw these provisions weakened. South Africa, which the same month became the first country in the world to roll out bedaquiline to all eligible patients with MDR tuberculosis (and at a reduced price) protested and negotiations were reopened. As we went to press, it was unclear whether the text would be reinstated.

Last month, WHO issued a rapid communication summarising key changes it will be making to its guidelines on the treatment of MDR tuberculosis. These include prioritising newer oral drugs, including bedaquiline, over injectables. The changes are justified by an individual patient data meta-analysis published in The Lancet last week, which found that “the traditionally used drugs for treatment of multidrug-resistant tuberculosis, especially oral second-line drugs and even the injectable drugs, appear to be less effective than the later generation fluoroquinolones, linezolid, bedaquiline, clofazimine, and possibly the carbapenems”. New trials are also underway to find shorter, less debilitating, treatment regiments for MDR tuberculosis, including the SimpliciTB and endTB trials.

There are many priorities in the complex and centuries-long fight against this cruel disease. But to suggest, as did a US representative at the recent civil society hearing ahead of the HLM, that global efforts should focus on improving health systems and new tools, rather than being “distracted, as we so often are, into a discussion of access to medicines, intellectual property flexibilities, or compulsory licensing” is plainly absurd. New tools include new (expensive) medicines and health systems cannot improve if WHO-recommended regimens cannot be afforded. Will the HLM make a difference? Not as long as commercial protectionism trumps social justice.