TB Is Changing: The approach to its treatment must, too
Editors note: On Tuesday, NextBillion Health Care will feature a Q&A with Dr. Madhu Pai from the McGill International TB Centre, who will discuss key successes and challenges of the IPAQT coalition (more on this below) as well as future opportunities for shaping the TB diagnostic and medicine markets.
Tuberculosis (TB) remains a leading cause of death worldwide, particularly among vulnerable populations such as children, women of reproductive age and people co-infected with HIV. Twenty-two high-burden countries account for more than 80 percent of TB cases worldwide.
In addition, the face of TB is rapidly changing with a growing concern over multidrug-resistant (MDR) TB and extensively drug-resistant (XDR) TB. These new strains have forced programmatic changes in how TB is addressed in many high-burden countries, placing a higher demand on effective diagnosis and faster initiation of treatment.
Despite efforts to improve diagnosis, TB case detection remains low globally – less than 60 percent in low-income countries, according to the World Health Organization. For newer, drug-resistant strains of TB, the issue of diagnostic accessibility is particularly challenging. Fewer than one in 20 new TB patients has access to drug susceptibility testing (DST), which can determine whether a patient is resistant to the most commonly available and affordable treatment methods.
India’s TB burden
India has the world’s highest burden of TB and increasing rates of drug-resistant strains. Diagnosis is particularly important in India to ensure a timely start to treatment and to reduce the period of transmission, cutting down on new cases. The Indian government has made progress providing free TB diagnosis and treatment to all patients in the public health sector. But more than half of all Indians seek initial care for most health concerns, including TB, in the private health sector, which has made less progress improving access to quality TB diagnosis and medicines.
The typical route of initial TB diagnosis and eventual care in India involves several visits to a variety of care providers, including informal private practitioners (e.g. unlicensed pharmacists), licensed private care providers and, finally, free care from a public health clinic. Long delays in appropriate diagnosis and treatment – often not obtained by patients until they reach a public health clinic – lengthen the period in which patients transmit the disease to others.
For drug-resistant forms of TB, the challenge of diagnosis takes new shape. Many of the previously used diagnostics do not detect drug resistance among patients and therefore are of little use interrupting the cycle of resistant TB strain transmission. There are several diagnostics that can help detect drug resistance; however, they often involve a large financial investment in equipment and/or testing materials. In the public sector this may be mitigated through a combination of governmental support and donor funding as well as the ability to negotiate lower prices direct with the manufacturers for larger volume orders of diagnostics.
In contrast, the private health sector is often fragmented, with many small businesses purchasing independently, meaning they’re unable to secure the same volume orders at reduced prices. Also, private health care providers lack the same incentives to engage in newer diagnostic markets that require greater capital investment with higher risks for return on investment. While often a source of TB treatment mismanagement – including incorrect use of diagnostics, poor prescribing practices and a lack of supervision to ensure appropriate medicine use – the private sector is also a market with high patient demand that is ripe for improvements in TB care. This is where the Initiative for Promoting Affordable, Quality TB tests (IPAQT) comes in.
Engaging with the private sector
IPAQT is a partnership that engages private health care labs in India by offering them three WHO-approved TB tests at lower, negotiated prices in exchange for their commitment to provide quality care to patients and to pass price reductions down to the patients purchasing such tests. In addition, the initiative engages with industry groups such as the Federation of Indian Chambers of Commerce and Industry to ensure appropriate private sector buy-in to this business opportunity.
More than 30 private sector labs across India and other stakeholders have joined this initiative to offer three TB diagnostic tests at or below negotiated “ceiling prices”:
Gene Xpert test – 1,700 rupees
Hain Genotype test – 1,600 rupees
Mycobacteria Growth Indicator Tube (MGIT) test – price under discussion
The initiative has made a great impact in replacing non-preferred diagnostic tests with WHO-approved tools across India. This coalition has identified a truly effective way of engaging with the private sector to both improve provider awareness of new, approved diagnostics and encourage coordinated use and increased community awareness of appropriate diagnosis for TB. That means patients in India are better able to afford quality diagnostic TB tests at their private health provider, which is their first, preferred point of contact with the health sector.
In addition to the private health care providers that have committed to this initiative, the coalition also includes leading nonprofit and academic groups in the field of TB diagnosis and treatment.