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In his book The Great Escape, Angus Deaton aptly summarizes the keys to achieving progress, “new knowledge, new inventions, and new ways of doing things…” In the context of Tuberculosis (TB) prevention and management, these critical measures are further echoed in the World Health Organization’s (WHO) Global TB Report,2021. The report, along with other data indicates that we are making commendable progress in generating new knowledge, new inventions and innovating in TB prevention, screening and treatment. This progress is resulting in a positive outcome shift, propelling us to meet the END TB Global 2030 targets. Having spent the past two years supporting Tuberculosis drug and diagnostic country introduction, I’d like to highlight a few of my favorite TB successes/milestones in the thematic areas of screening, prevention and treatment in Lesotho.
Screening and Diagnosis: To increase TB case detection amongst people living with Advanced HIV Disease, in 2020, Lesotho adopted the use of TB Lateral Flow Urine Lipoarabinomannan Assay (TB LAM), a point of care rapid diagnostic test, which has great potential to increase case detection. Advantages associated TB LAM usage include: ease of obtaining specimen sample (urine) and usage within primary care facilities, thus increasing case detection across the continuum of care settings. A promising intervention indeed.
TB Preventive Therapy (TPT): TB preventive therapy is a critical active TB –averting intervention. However, traditional regimens such as Isoniazid Preventive Therapy (IPT) require patients to stick to treatment for 6-36 months. This length of time often leads to poor adherence and defaulting. An alternative option to such regimens is 3HP, a short course TPT regimen formed of two TB drugs, Isoniazid and Rifapentine. Unlike IPT, 3HP therapy can be completed over the course of 3 months. Lesotho adopted 3HP usage in 2019, a decision which is proving to greatly benefit for TPT recipients.
Treatment: Similar to long-course TPT, lengthy treatment times for multi-drug resistant TB (MDR-TB) are not patient-friendly, and increase the likelihood of poor adherence and subsequent treatment defaulting. In an effort to explore less toxic, cost-effective shorter treatment courses, Lesotho joined the endTB initiative, which is currently running a multi-country observational study which aims to assess the effectiveness of two new treatment drugs: Bedaquiline and Delanamid in the management of MDR-TB. In 2021, study enrollment was reported to be complete in all countries, a crucial step to carrying out and completing the study. With data from other studies signaling improved treatment outcomes from using this regimen (Kim et al, 2018), this study promises to generate much needed evidence on these two novel drugs!
Having highlighted these significant achievements, it is important to appreciate that in order for Lesotho and the rest of the world to eliminate TB by 2030, more targeted efforts are required. In Lesotho for example, gaps in access to screening for key populations threaten to stunt TB outcomes. A group of concern is men who, compared to their female counterparts; often present to care late, at a stage where they are severely ill. We should leverage on our success in developing differentiated service delivery models and pathways for HIV/AIDS management and transfer key lessons across the TB care cascade. From an adherence standpoint, we should dedicate more effort towards optimizing adherence strategies, by moving beyond Directly Observed therapy (DOT) and tapping on adherence technology.
The furtherance of TB knowledge and management optimization hinges on our investment towards TB research and access to care across the entire TB care cascade. Globally, we are making somewhat notable progress; with the WHO Global TB report of 2021 documenting that annual investments made in TB research as well as access to TB prevention and care amounted to US $ 901 million and US $ 5.3 billion respectively. These figures however, fall short of the set UN targets: US $ 2 billion annually for TB research, and US $ 13 billion annually for access to TB prevention and care. There is room to invest more.
May this day fuel our commitment to ending the Tuberculosis epidemic and saving lives.