New priorities, new challenges

Francis Varaine is the coordinator of MSF's Tuberculosis Working Group. In this interview, he underlines the urgency of identifying new diagnostic means and treatments suited to MSF's operating environment. He also discusses MSF's priorities for 2008.

25,000 patients in 100 programs

Over 25,000 patient have been treated for tuberculosis in more than 100 projects. In half of these projects, tuberculosis treatment is integrated into the general care offering. In a quarter of projects, it is integrated into HIV/AIDS programmes. The number of patients under treatment for TB-MDR and is increasing: 580 in 2007, as against 260 in 2006.

Where exactly are we today in terms of tuberculosis diagnosis and treatment?

First, on the part of international institutions, we are today witnessing a sea change as regards the stakes involved in the diagnosis and treatment of tuberculosis. The World Health Organisation is beginning to recognise the need for new tools, as well as a greater amount of research. "At the MSF level, we must continue to show our results, and present the various approaches inherent in our programs, thereby demonstrating their effectiveness. But we need also to show their limits, due to the lack of suitable diagnostic and treatment tools. "As regards multi-resistant tuberculosis, the WHO estimates there are some half-million new cases every year, worldwide. A few years ago, we thought that this form of tuberculosis was limited to countries in the ex-Soviet Union. What we are now finding is that wherever we apply diagnostic means, we come across cases! "With the present treatment (which lasts two years and has many side effects), it is not realistic to imagine that all cases will be treated correctly. Therefore a simpler and more effective treatment must be found as soon as possible.

So what exactly have been the main changes in MSF's programs over the last year?

"Well, we continued our efforts to obtain generalised use of six-month treatment instead of eight months for simple tuberculosis: this shorter treatment time works out more effective. We also opted for self-medication, associated with sound follow-up of the patient. "Additionally, to increase our ability to diagnose multi-resistant tuberculosis, we upgraded our collaborative work with the laboratory of the Institute of Tropical Medicine at Antwerp. An MSF biologist and laboratory technician occupy salaried posts there, producing cultures and antibiograms for all our projects, in particular for high-risk patients (those suffering from therapeutic failure or relapse).

Finally, what are MSF's priorities for 2008?

One priority is diagnosing tuberculosis in HIV patients: we are running a pilot project at Homa Bay in Kenya, where we have introduced cultures for all HIV patients where we suspect tuberculosis. This represents a large investment, in both financial and human terms. The employed technique gives a result in two weeks, instead of one month with the usual method. Such a time-saving is essential in this region of Kenya, where 80 percent of tubercular patients are co-infected with HIV. "More specifically, we want to improve diagnosis of multi-resistant tuberculosis in patients infected with HIV. Most often, these patients die before we can even confirm the diagnosis by tests [the waiting time for results from antibiograms is two to three months, using standard techniques]. We therefore want to explore the feasibility of molecular techniques (PCR) in the field: these tests allow calculating degree of resistance to Rifampicine, and give results in less than 24 hours. "Another priority is to improve monitoring of nosocomial infections in our care structures. This work is comprised in our top-down programs, but is often disregarded in other programs, particularly in Africa. Our care structures must not themselves represent infection-risks.