Trade, foreign policy, diplomacy and health

3. Tuberculosis control

Jim Yong Kim, Aaron Shakow, Arachu Castro, Chris Vande, Paul Farmer

TB control: DOTS (3)

One obstacle facing DOTS is MDR-TB, where:

  • effectiveness of DOTS is lower
  • drugs more expensive
  • treatment longer (18-24 vs. 6 months)

HIV/AIDS compromises effectiveness of DOTS, TB leading cause of death among those with HIV. Both cases may move TB control from ‘important & affordable’ to ‘important & unaffordable’.

One obstacle facing DOTS is where drug-resistant disease is already prevalent, where a more than half of these patients will not respond to standardized short-course chemotherapy regimens, even if they are fully supervised to ensure compliance. Worse, when cure rates are high for drug-susceptible TB, but much lower for drug-resistant TB, strains of drug-resistant TB begin to constitute a growing proportion of new infections. Eventually, treatment efficacy will be compromised to the point that DOTS, once a cost-effective intervention, no longer remains one. Treatment of MDR-TB takes longer than treatment of drug-susceptible TB and it is considerably more complicated. The standard requires 18-24 months of treatment, as opposed to the 6-month regimens used in DOTS, and MDR-TB requires use of 'second-line' antituberculous drugs, which are significantly more expensive than first-line drugs.

These drugs are more toxic and associated with difficult adverse effects, requiring close and attentive medical management, and attentive social support. TB is the leading cause of death among people with HIV infection. HIV/AIDS compromises the effetiveness of DOTS. As in the case of MDR-TB treatment, many people in both the funding and global health communities have expressed concern that these additional interventions will move TB control as a whole from the 'affordable and important' category into another category for which resource limitations will preclude appropriate action. It is precisely at this point where the global public good for health (GPGH) concept might be most helpful.