In the giddy talk of a turning tide and the chance for an “AIDS-free generation,” a look at the recent history of responses to tuberculosis, the science surrounding that disease as it stands now, and what, after a period of premature complacency in the middle of the last century, yet is to be done to see a generation free of it, offered a tempering note on the last day of AIDS 2012, at the Walter Washington Conference Center in Washington, DC.
As the participants in the Global Village downstairs disassembled their temporary conference center homes to return to their disparate parts of the earth, panelists at a session titled “Looking to the Future in HIV and TB” gave a glimpse of how a disease that had been settled as curable, looms too large now worldwide to be ignored Washington.
With the lure of a commentary from actress and comedian Whoopi Goldberg coming at the end and packing Session Room 1, researchers looking for better, quicker treatment and diagnostics, a vaccine – and funding to make those happen, reflected on what this moment in both epidemics around the world offers.
Mark Harrington, executive director of Treatment Action Group, and co-chair of the session, highlighted the irony of optimism for an era in which AIDS can be cured.
“Guess what,” he said, “we’ve been in the TB cure era since before I was born.”
Still, the disease remains the biggest killer of people with HIV, while most of those with tuberculosis do not have HIV. Children who get active tuberculosis at their schools or their homes, continue, untreated to die, he said. “Every single one of those cases can be prevented, treated, cured.”
Researcher Alison Grant of the London School of Hygiene and Tropical Medicine continued to highlight the déja-vu-all-over-again quality of recent HIV breakthroughs.
“In high tuberculosis transmission settings, treatment as prevention is very old news,” she said. “Tuberculosis infection control is tuberculosis prevention. Earlier tuberculosis treatment is tuberculosis prevention.”
But efforts to get treatment to those who need it, for as long as they need it, and to respond to drug-resistant strains remain a work in progress.
The future part?
After a “false optimism” in the 1960s dried up funding for tuberculosis research, Richard Chaisson, director of the Johns Hopkins University Center for Tuberculosis Research, money began to flow again, in dramatic, if “woefully inadequate” response to the surge of the disease worldwide. And belated and insufficient as the response to the challenges of resurged and increasingly drug-resistant epidemic, “the return has been spectacular,” he said.
It includes the upsurge of new technologies, new tests, and quicker diagnoses. The uptake of the GeneXpert test which can diagnose drug-resistant cases in hours rather than weeks, has been “swift and dramatic,” he said.
But the challenges, in financial and human resources, in sustainability, remain in place, leaving “enormous opportunities to miss benefits,” he said. They include: tests not ordered, not taken, not read.
In addition to obstacles that strew the path to diagnoses, he reiterated, the development of new treatments that can be afforded, distributed, tolerated and be effective will continue to be lengthy.
Chaisson suggested adding a fourth zero to the zero declaration of “zero TB deaths, zero new TB infections, and zero TB suffering and stigma,” that would make all the preceding ones possible “add a zero to the level of funding,” he said. “If we add a zero, there’s almost nothing we can’t do.”
The future then, in a world with an additional digit of funding and sustained commitment?
Combination prevention, said Grant – screening in the communities, households, schools of those affected, quicker diagnoses, shorter treatment, maximizing antiretroviral coverage of those living with HIV.
Comprehensive efforts, that pay attention to tuberculosis and HIV in prison settings, involve ministries of health in prison health and that eliminate silos in other health care settings, said Haileyseus Getahun of the World Health Organization.
The challenges there include the length and expense of trials that are needed, lack of validated animal models of the disease, and the diversity of strains, populations, and environmental factors a vaccine would address.
His list of reasons for optimism is as long, though, and equally concrete, including the existence of natural protection (80 to 90 percent of people don’t get the disease when infected) and the existence of a vaccine that is effective, briefly, in children. While application remains years away, multiple phase three studies of vaccine candidates will take place in the next decade, he said.
Watching all of this patiently was Whoopi Goldberg, whose commentary came last, who drew so many photographers to the front of the room she asked nicely for them to back off (“Y’all want to sit down? You’re distracting me . . .”) and who offered a simple solution.
“If you see a problem, fix it,” she said. “And this seems to be a worldwide issue – we see a problem, and we go to dinner.”