This is a guest post by two doctors with vast experience in treating multi-drug resistant tuberculosis (MDR-TB), Drs. Salmaan Keshavjee and Paul Farmer. Farmer is co-founder of Partners In Health and Keshavjee has treated MDR-TB patients through Partners In Health programs for the last decade. Until three months ago, Keshavjee was the chairman of the Green Light Committee of the Stop TB Partnership, which oversaw the distribution of second-line TB drugs to countries. They wrote this post in response to an interview on Science Speaks with Dr. Ezekiel “Zeke” Emanuel, a senior Obama administration official at the Office of Management and Budget. Emanuel’s interview can be found here.
The world is in the midst of a multi-drug resistant tuberculosis (MDR-TB) epidemic. This airborne disease killed an estimated 1.5 million people over the last decade—a troubling number that reflects the vulnerability of a number of populations, including children, who comprise 10% of patients, and those with HIV/MDR-TB co-infection, who face high mortality rates without rapid and appropriate care. But MDR-TB is treatable, and when patients are diagnosed early and put on the correct regimen of second-line TB medications, cure rates can be as high as 90% in some settings.
Dr Emanuel saw one facet of MDR-TB control: hospitalization for very sick people. We completely agree with his comments that more hospital beds alone will not be enough to address this growing epidemic. In reality, the majority of people receive care on an outpatient basis. This is the case for TB, MDR-TB, and HIV. Ambulatory models of MDR-TB treatment delivery—including treatment at health clinics and in patient homes—have been used for years. In fact, this is how some high-burden MDR-TB settings (like Georgia, Latvia, Lesotho, Nepal, Peru, and areas of the Russian Federation) are now able to offer universal access to MDR-TB treatment. These well-described models rely on hospitals only as a back-up for the very sick, and have systems in place to ensure that patients receive the two-years of daily treatment required to cure this disease. Therefore, we need more funding for this treatment and approach, not less.
Dr Emanuel correctly identifies two of the main barriers to treating MDR-TB: difficulty in diagnosis and limited access to second-line TB medicines. New rapid tests can provide results in 2 to 48 hours, and will soon dramatically improve our ability to find patients early in the course of illness—when treatment is most effective. While we still need a true point-of-care test for TB and drug-resistant TB, this is a major advance.
The bitter truth about drug access is that most of the second-line TB drugs used in MDR-TB treatment are off-patent and 30 to 50 years old; yet, many MDR-TB regimens cost 25 times more than first-line HIV regimens. There is no way that para-aminosalicylic acid (PAS), a 50-year old analog of aspirin and an essential second-line TB medicine, should cost more than patented HIV drugs do. But it does. Since 2000, prices for off-patent MDR-TB medications have actually increased, despite the important contribution of UNITAID, a multi-lateral donor whose aim is to lower drug prices.
However, let us remember that a number of factors led to major reductions in the price of antiretroviral therapy and HIV diagnostics. These included: significant efforts at price negotiations and advance purchase commitments by organizations like the Clinton Health Access Initiative and Médecins Sans Frontières; serious commitments to treatment scale-up by national governments, large implementers, and donors, including the Global Fund to Fight AIDS, TB, and Malaria and the President’s Emergency Plan for AIDS Relief; and a large-scale advocacy effort by the World Health Organization and UNAIDS through their 3 by 5 Initiative. Therefore, the answer to high MDR-TB drug prices is not to stop treating patients, but to move rapidly towards universal access to treatment while simultaneously redoubling pooled procurement and advance-purchase initiatives, and turning to other proven price-cutting strategies. That we rely on half-century-old drugs in the first place—requiring a two-year, often painful treatment regimen—speaks to the dire need for new research and development for TB drugs. This is a market failure and an advocacy failure, and patients should not be punished for it.
The United States must send a clear message to the world that treating MDR-TB is imperative. It also happens to be eminently affordable because the alternative is that millions of patients will die—but not before infecting millions of others who will also need treatment. Since tuberculosis transmission is airborne and occurs in buses, airplanes, malls, hospitals, prisons, and communities, it is impossible to stop the spread without treating those who are already sick. We either use resources wisely now, or pay much, much more later. Let’s not miss this opportunity to do it right.