In the two decades since he began his medical career, Dr Isaac Chikwanha has witnessed the dramatic advancements in treatment available for HIV patients. At the same time, he says TB patients still face the same limitations they did years ago. Dr Isaac talks about the challenges TB patients face and how medical practitioners can find innovative, yet simple approaches to help more people.
Having worked in both HIV and TB care why do you think there has there been more progress in treating HIV?
That’s really a million-dollar question. It’s probably because tuberculosis is a disease we’ve had for such a long time, an ‘old disease’ we’ve taken for granted and (sort of) managed to keep under control – at least until we started seeing multi-drug resistant TB (MDR-TB).
In HIV treatment today, we have so many options. If one drug doesn’t work, doctors are scratching their heads looking at all the options saying ‘do I use this or this or this drug?’
And each one of them is better than what was there just a year ago. For TB, we are literally still fighting with option 1, fighting so we actually have other options available that are stuck or not yet in the pipeline.
One lesson from HIV is also how patients demanded the medicine they needed. We had demonstrations globally in the early days of ARV’s – patients asking for these drugs. And governments caved in and they invested.
Now, these drugs are everywhere. We need the same to happen for TB. We need a lot of activism. We can push from the top among decision-makers, but we also need people to push from the grassroots.”
How do we treat drug-resistant TB?
The important thing to understand is that TB is treatable. The drugs we have available at the moment are not the best drugs to treat it, particularly for multi-drug resistant (MDR) TB and extremely drug resistant (XDR) TB – with treatment taking up to 2 years or more. But it is still treatable.
To treat drug-resistant forms, there are 23 different medicines you can use, in different combinations. For simplicity purposes they are grouped into ‘families’: Group A, Group B, Group C, and Group D; and the exact regimen a patient is given is made up of a combination of drugs from each ‘family’.
There’s set criteria you use to select the right drug combinations for a patient. In low resource settings, TB programmes use guidelines put together by the World Health Organization (WHO), which has a recommended regimen that countries can use to sort of build their own regimens around TB Medical Assistance.
What is the best way to treat and manage TB?
The best model of care for TB is to manage the patient and not just the disease.
One TB patient has the potential to infect 10 people each year. So, if I’m in a village and I have TB, I cough and infect 10 people. Even if I come to the clinic for treatment, those 10 will cough and infect 10 others each. In a year you could potentially infect the whole village.
That’s why, once you have somebody with TB, you should do contact tracing: go back to the village and basically screen everyone the patient has come in contact with, or who’s been exposed.
Waiting for people suspected of having TB to come to the health centre causes delays in diagnosis, in treatment initiation and adds a financial burden. So this is probably the most effective way to control TB is by breaking the chain of transmission.
As clinicians, we don’t do this very effectively yet. One reason is we are very, very medical in our thinking: ‘We are doctors, we treat the disease’. And this is where the public health experts need to come in.
You have to offer a full package of care with social support, counselling, even food where it’s needed (because the medication needs to be taken with food). TB is not just a medical issue.
What tools and innovations help in the management of TB?
In low resource settings, access to TB care is a huge challenge for patients. Often the further you go from towns, the fewer services you have – no roads, electricity, water.
That means there’s a higher chance that patients struggle to go through the full treatment process. So the ideal model of care is to have TB services as close as possible to the people.
In PNG we had to resort to boat rides across choppy waters to reach patients in really remote places. We also tried to use unmanned aerial vehicles (drones) to bring the patient sputum* samples to the facility for testing
But one mistake we can make is thinking innovation always means introducing more technically savvy things. Innovation could actually mean simplifying things, using tools that are not high-tech. We don’t always need trucks or drones to transport samples for testing, for example, we could use donkeys.
We know people come from villages every day to the market, with heavily laden donkeys to trade. We can work with them to come to the hospital to collect medication or test results. And that could be a naturally inbuilt process.
We could work with traditional medical systems because in some cultures, like in PNG, these are an integral part of the health system. We know people consult them even before they seek modern medical services.
Despite our training and modern medical technologies, we can’t rule them out. So we should try and find ways to integrate them, teach them about TB symptoms, and they could act as community health workers to help with screening, who then refer suspected patients to health centres.
Why do you work in TB care?
When I started working in TB and HIV, we didn’t have many treatment options to help patients. If you are an enthusiastic, newly baked doctor you get frustrated. After, when I joined MSF, we had options – not necessarily the best ones but at least some options where you can give patients hope. That was very exciting for me.
When the new TB drugs came around (like delamanid and bedaquiline), I thought: “Yes, we can actually have better treatments! It’s not just about giving patients hope for survival; they can actually survive without deafness (which is a side-effect of some injections), or they can be treated successfully in a shorter period of time – in 9 months – without having to use old injectable drugs.
I am very passionate about working in TB. I probably have romantic ideas of what’s possible: I think it’s actually doable. It’s really, really doable. I’m a product of Africa – I was trained in Africa, I have seen what’s possible in other parts of the world. And I know it’s possible. It just needs effort and investment.
* In countries where TB is most prevalent, diagnosis depends largely on the microscopic examination of sputum, or lung fluid, for the TB bacilli.