Global TB & HIV–The Promise and Perils Ahead

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Physicians on the front lines of the global tuberculosis epidemic have faced an uphill battle against this deadly scourge, especially with the rise of virulent new drug-resistant strands of this ancient germ and outmoded drugs and diagnostics.

But the medical landscape for TB could change dramatically in the coming years—with new tests and better drugs paving an easier path for TB treatment and care. That upbeat assessment comes from William Burman, MD, an TB specialist and associate professor of medicine at the University of Colorado, speaking at a global health news conference during the Infectious Diseases Society of America’s 47th Annual Meeting last weekend.

“We could have new TB drugs approved by 2011,” said Dr. Burman, who is also a member of the Global Center’s Scientific Advisory Committee. Two drugs currently in the pipeline look particularly promising, he said, because they work in new ways and appear to be very potent.

Those drugs and others in development, along with exciting new tests that could make tuberculosis diagnosis faster and easier, have the potential to “revolutionize the treatment of tuberculosis,” Dr. Burman said. “We can start to see the outlines of major improvement for TB treatment for patients,” with shorter therapy and possibly safer therapy too.

Dr. Burman said he sensed a renewed commitment in the US and other countries to TB research and treatment, a much-needed shift for this often-neglected forgotten disease. But he noted that the scope of the threat is still grave, with 9 million new TB cases a year and more than 1 million deaths, including an estimated 100,000 children who die from TB annually. Drug-resistant TB is of particularly concern, since it is extremely hard to diagnose and treat with the medical weapons currently available.

“The message is that this is a time of great need,” he said. And “it’s also a time of great opportunity.”

There was no similar talk of turning the corner in the battle against global HIV/AIDS at the news conference. Instead, two HIV/AIDS physician-experts said the gains made in the last decade against this deadly epidemic are tenuous, and developing countries could all too easily lose ground if leadership and resources wane.

“We’ve progressed from a situation of calamitous magnitude to one that’s extremely serious,” said Mark Cotton, MD, a professor of medicine at Stellenbosch University in South Africa. “And that progress is very fragile … If the structure to maintain [ARV treatment] breaks, everything’s going to break.” Click here to get to IDSA’s audio file of the news conference.

Dr. Cotton detailed the difficulties of treating HIV in infants and children–his area of expertise. Most doctors and nurses are afraid to do it, he said, because of the complexities of diagnosis and the lack of appropriate drug formulations for children.

He said there are approximately 2 million children living with HIV and only about 10 percent of them are getting antiretroviral drugs. For those children who do have access to ARVs, the drugs are often toxic and not well tolerated.

Researchers need to focus urgent attention to developing new drugs and easier formulations for children, Dr. Cotton said. For example, there’s one tablet that kids 4 and older can take, but it’s very large and cannot be cut. With a little bit of work, the pill’s design could be changed to a sprinkle or crushable tablet, with great effect, he said.

Asked about the impact of PEPFAR and similar global AIDS programs, Dr. Cotton said these initiatives are vital. He pointed in particular to a program in South Africa and partly funded by USAID that teaches general practitioners and nurses how to properly diagnosis and treat HIV in infants and children—something that is well beyond the capacity of South Africa’s overwhelmed health system.

“When I speak about the fragility of this process, we are extremely anxious and nervous that this is going to disappear,” he said. “And in the absence of activity … there’s potential for massive failure.”

Another South African physician-scientist and HIV specialist, Quarrisha Abdool Karim, MD, noted that South Africa is at an important turning point in HIV/AIDS treatment.

“We’ve come to the end of almost a decade of denialism,” said Dr. Karim, an associate professor of epidemiology at Columbia University and an associate professor of public health and family medicine at the Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, in South Africa. And the new South African government is incredibly committed to battling the epidemic, she said.

But there’s “cause for concern” about navigating this transition, particularly when there seems a pullback in funding for AIDS from donor countries. “It’s going to be a huge challenge for all of us … to look at how we use this period of economic recession when funds are declining to continue the effort we put into place and do a better job of that,” she said.

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