Lesotho project starts treating patients and testing model for tackling drug-resistant TB

	PIH community coordinator Likhapa Ntlamelle (right) talking with two MDR-TB patients

Barely five months after Partners In Health and the Open Society Institute announced plans to create a model for treating overlapping epidemics of multidrug-resistant tuberculosis (MDR-TB) and AIDS, the program in Lesotho is up and running. At least 21 patients have already started receiving the complex combination of drugs needed to treat MDR-TB. In addition, most of the work had been completed to equip and train the national tuberculosis laboratory to perform the lab tests needed to diagnose cases of drug-resistant TB, and to turn a dilapidated hospital into a state-of-the-art center for TB treatment.

With nearly one-third of its adult population infected with HIV, Lesotho may have the world’s highest incidence of tuberculosis as well. TB epidemics almost always shadow AIDS in populations where many people’s immune systems have been weakened by HIV. Evidence to date suggests that about one in three cases of TB in Lesotho is resistant to at least one drug, and more than 75 percent of patients with TB are also infected with HIV.

Although the exact scale of the epidemic is not yet known, Dr. Salmaan Keshavjee, a physician at Brigham and Women’s Hospital who is the Deputy Country Director of PIH's program in Lesotho, estimates that 1,000 to 1,300 people in Lesotho may currently be living with and infecting others with MDR-TB. “Even if you find half of that,” he says, “500 cases a year is an overwhelming number for a country the size of Lesotho,” with a total population of barely two million. In comparison, PIH’s partner organization in Tomsk, Russia, sees 300 to 400 cases of MDR-TB a year.

MDR-TB is particularly dangerous and difficult to treat for many reasons. The typical first-line drugs for TB are ineffective against these strains, forcing MDR-TB patients to take second-line drugs that are more costly, carry extensive side effects, and must be taken every day for up to two years. If the medications are not taken consistently, the disease can develop resistance to these drugs as well, fueling the spread of even more deadly strains known as extensively drug-resistant TB or XDR-TB. An outbreak of XDR-TB in the South African state of Kwazulu-Natal, just across the border from Lesotho, killed 52 of 53 HIV-infected patients in 2006, prompting fears that the disease could prove untreatable and uncontrollable in populations with high rates of HIV. OSI’s $3 million grant to PIH aims to build on our success at treating MDR-TB in Peru and Russia to develop, test, and disseminate a model for treatment of drug-resistant TB in areas with high prevalence of HIV.

By the end of August, 21 patients in Lesotho had already begun the complex drug regimen for MDR-TB, which is just one part of the comprehensive approach used successfully at other PIH sites. The program also includes food support, as well as frequent visits and support from community health workers, says Dr. Hind Satti, the director of PIH's MDR-TB program in Lesotho, based in Maseru, Lesotho’s capital city.

In the coming weeks, the project plans to supply drugs and services to 40 patients, and hopes to scale up to a total of 100 patients by the end of this year, says Dr. Satti. PIH staffers worry that this will only be a drop in the bucket. “If we identify another 100, what’s going to happen to them?” asks Dr. Keshavjee.

Although eager to include more patients in the drug treatment program as quickly as possible, Dr. Keshavjee also acknowledged that the process will be more complicated than just putting patients on medication. “We need to scale up properly so that these people can get appropriate care in a manner that won't lead to the creation of more resistant strains,” he explained. “We need the resources to provide high standard community-based treatment, using the accompagnateur model [in which community health workers provide directly observed therapy and psychosocial support] that we have used in Haiti, Boston, and elsewhere.”

	With new equipment and training, the national TB lab in Lesotho will be able to test for MDR-TB instead of sending samples to South Africa

To tackle this challenge, the program first requires equipment and staff to effectively identify patients with drug-resistant strains of TB, and monitor the progress of treatment. To do this, PIH is working with the Ministry of Health and the Foundation for New and Innovative Diagnostics (FIND) to build the capacity of Lesotho’s national TB laboratory. A lab in South Africa currently processes samples for Lesotho patients, problems with shipping specimens and receiving results are common. Also, the South African lab can only handle a small portion of what’s needed to run a truly effective program. Renovations and new equipment, such as a state-of-the-art negative-pressure ventilation system and a rapid culture machine operated by lab technicians who have been trained and hired locally will all help Lesotho’s lab become a vital resource for the MDR-TB treatment program. FIND has sent a full-time lab specialist to help develop this essential laboratory capacity.

Other new and important resources for the treatment program include a refurbished TB clinic and a hospital to help identify and care for extremely ill patients. These renovations include methods of minimizing the risk of TB patients infecting others, such as a a state-of-the-art ventilation system, a waiting room for TB patients separate from the general outpatient waiting area, and a TB unit separate from the HIV unit to protect patients with weakened immune systems. Other improvements include a new pharmacy.

Training health workers to treat MDR-TB patients is another important component of the program. Earlier this summer, about 75 health professionals from three regions of Lesotho received training, said Dr. Satti. She hopes that in the next few years, the program will create a training manual and establish public training centers for regions throughout the country.

In the future, PIH hopes that the program will become a model that can eventually be scaled up on a national level. But ultimately, MDR-TB is a global problem, says Dr. Keshavjee. The aim is not just to create a successful program in Lesotho but to develop and test a standard that the global community can work together to implement internationally. “This problem is not going to go away, it’s only going to get bigger,” he says, “It has to be the international community working together to come up with a solution.”

[published August 2007]