Drug-Resistant TB and PEPFAR Editorial Packet

In phase two of the President's AIDS Initiative, address the threat of drug-resistant TB

February 2008 — During his week-long trip to Africa, President Bush noted the progress made against AIDS in that region, thanks in no small part to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). The emergence of drug-resistant tuberculosis, however, threatens to undermine that progress. People living with HIV/AIDS are much more susceptible to TB, and without effective diagnosis and treatment of drug resistant strains, TB becomes a rapid death sentence. With TB already the biggest killer among people with HIV/AIDS, these drug-resistant cases — far more difficult and costly to treat — must be detected and cured, so the deadly cycle of transmission can be stopped before death rates again skyrocket.

The president's trip concluded shortly before the Wednesday, February 27, meeting of the House Foreign Affairs Committee, where members will take up the reauthorization of PEPFAR for the next five years. This House Foreign Affairs "mark-up" of PEPFAR also comes the day after the release of the World Health Organization's latest surveillance report on drug-resistant TB globally, including the emerging threat of extensively drug-resistant TB (XDR-TB), which has demonstrated death rates approaching 100 percent in some settings. The report, the largest survey to date of TB drug resistance, offers a sobering assessment of a burgeoning health crisis that needs to be rapidly brought under control. Last year's incident concerning Atlanta lawyer and drug-resistant TB patient Andrew Speaker demonstrated how easily drug-resistant TB could be spread through air travel.

To provide comment and perspective on the WHO report, RESULTS Educational Fund is hosting a media conference call at 1:00 PM (ET) on Tuesday, Feb. 26, with Dr. Mario Raviglione, director of the World Health Organization's tuberculosis department, and Abigail Wright, primary author of the report. Regarding MDR- and XDR-TB, Dr. Raviglione has said, "It is possible that in some settings drug-resistant tuberculosis could completely replace standard tuberculosis."

In considering ways to sustain and improve PEPFAR, members of Congress must include directives and funding to urgently address the global TB epidemic, including the growing presence of MDR- and XDR-TB. When PEPFAR was first authorized, little attention was given to TB and its impact on people living with HIV/AIDS, and XDR-TB had not even been officially identified. While U.S. AIDS funding has made major gains, TB funding has languished — and this neglect now leaves both programs horribly vulnerable. Armed with the knowledge we now have — and the evidence of rising deaths — Congress must connect the dots to see that the fight against AIDS will not ultimately succeed without an equally aggressive effort against TB.

The emergence of XDR-TB

XDR-TB is a consequence of our collective failure to adequately address the TB epidemic. For decades, TB programs and health systems have been shortchanged, leaving them ill-equipped to control a disease that kills some 1.6 million people a year — 4,400 people per day, despite a low-cost cure. XDR-TB occurs nowhere in nature. It's a human-made problem arising from inadequate or incomplete TB treatment provided in the context of under-funded TB control and weak health systems.

Since the Centers for Disease Control and Prevention first classified XDR-TB in March 2005, 42 countries have confirmed cases - including the U.S., Canada, Mexico, and the entire roster of G8 member states. Although XDR-TB represents a small percentage of overall TB cases, its high mortality rate and difficult treatment make it a global threat to public health. No one really knows how common XDR-TB is, because in those developing countries where tuberculosis is most common, all but a few nations have little capacity to test for drug resistance — let alone track the epidemic and respond.

Some facts about XDR-TB:

  • XDR-TB is resistant to not only the most effective first-line drugs, but also to critical second-line drugs. An outbreak of XDR-TB in KwaZulu Natal (KZN), South Africa, in 2006 killed 52 of 53 infected patients. A result of improper treatment and management of regular TB, XDR-TB is entirely human-made.
  • In the first group of 53 XDR-TB patients reported in KZN, seventy percent died within one month of being diagnosed with TB (untreated or ineffectively treated TB is rapidly fatal in people living with HIV/AIDS). Current methods of testing for drug-resistance can take between 6 to 16 weeks, so many HIV-positive patients with drug-resistant TB die before the disease can even be accurately diagnosed.
  • According to the U.S. Department of Homeland Security (DHS), in some sampled populations, XDR-TB has had fatality rates approaching 100 percent. DHS has identified XDR-TB as an "emerging threat to the homeland."

The Global Plan to Stop TB

Launched in 2006, this comprehensive 10 year business plan to fight TB, if fully implemented, will save an estimated 14 million lives and put humanity on track to wipe out one of our oldest and deadliest killers by:

  • Expanding access to high-quality TB testing and treatment for all
  • Treating 50 million people for TB
  • Developing more effective tools to diagnose and treat TB and creating a new vaccine

In June 2007, the WHO released the MDR/XDR Global Response Plan to complement the existing Global Plan, with strategies and resources necessary to address the MDR/XDR-TB emergency, including lab strengthening, infection control, more aggressive treatment, and prevention efforts. If fully implemented, the plan will increase by ten-fold the number of MDR- and XDR-TB patients being treated and cured under WHO guidelines.

The challenge for PEPFAR

As Congress prepares to reauthorize PEPFAR, it must also prioritize a comprehensive approach to TB. Failure to address TB will undermine the gains made in reducing AIDS deaths and could push us to an almost pre-antibiotic era In the TB battle. As Archbishop Desmond Tutu — himself a TB survivor — has written, "XDR-TB sounds a clamorous warning: without the political will to control TB, we will not only fail to defeat HIV but may enable the rise of an incurable, airborne disease."

Improving access to TB testing and treatment will not only directly address the biggest killer of people with AIDS, but can also help ensure the success of AIDS efforts. TB programs are one of the most important entry points for access to HIV testing, counseling, and comprehensive services and are therefore critical to reaching global HIV/AIDS treatment, prevention, and care targets.

The House majority draft of the PEPFAR reauthorization bill to be considered by the Foreign Affairs Committee on February 27 would provide at least $50 billion over the next five years to fund critical interventions for HIV/AIDS and TB, as well as malaria.[1] With $4 billion for a serious ramp-up of TB efforts between now and 2013, as well as at least a doubling of critical contributions to the Global Fund to Fight AIDS, TB and Malaria, this reauthorization, if passed intact, will go a long way to close the gap in the fight against TB. In doing so, it will protect the billions invested in AIDS efforts as well. Bold action by Congress, as embodied in the House's version of the PEPFAR reauthorization, can help bring these diseases under control, but there is no time to lose.


[1] President Bush has asked for $30 billion for the reauthorization of PEPFAR over the next five years - but this funding level equates to a near flat-lining of the current funding levels, and would slow the rate of progress.