Reaching the unreached and expecting the unexpected
Authors: Zoë Mullan
Journal: The Lancet Global Health (2014)

March 24 marked annual World TB Day, this year's theme being “reach the 3 million” who acquire tuberculosis every year but who do not get diagnosed, treated, or cured. Why do so many patients with this life-threatening infectious disease go under the radar? One reason, as Madhukar Pai and colleagues point out in a Comment this month, is that many people seek advice on their symptoms from care providers who have little to do with the evidence-based policies and procedures set out by national tuberculosis programmes. In some countries, such as India, half of patients with suspected tuberculosis are thought to visit private-sector medical services, under which use of appropriate diagnostics (including resistance testing), drugs, and follow-up cannot be guaranteed, and costs can be exorbitant. In other countries, services might be provided by a range of non-governmental organisations or by specialist public-sector entities (eg, army or prison health services) that operate out of the scope of national tuberculosis programmes. WHO's Stop TB Strategy already includes a public-private mix (PPM) component, and many countries are implementing successful PPM initiatives to map out, engage, train, and monitor all types of provider. But Pai and colleagues suggest going beyond such a top-down strategy and taking a more business-like approach. They give examples of “patient-centric” solutions that involve innovations such as social enterprise and telemedicine, treat the whole patient, and are driven by “community champions”. As is so often the case in global health, the one-size-fits-all approach is unlikely to provide all the answers, so adopting innovating solutions tailored to a region's specific situation seems sensible—as long as nationally led PPM efforts are not displaced. Elsewhere in the issue, Petros Isaakidis and colleagues unfavourably compare the tuberculosis response with that of HIV/AIDS in terms of the dynamism of both the scientific community and civil society. “It took less than 30 years until aspirational goals of zero targets were set for HIV”, they point out. “Tuberculosis, a disease as ancient as the mummies, only fairly recently acquired such aspiring and ambitious targets.” Quite. Yet the reluctance to grab opportunities continues, it seems. While attending the International Congress on AIDS in Asia and the Pacific last November, Isaakidis and colleagues searched in vain for a session on “the number one killer of people with HIV”. Whether the presence of “zero TB” was down to the conference organisers or to abstract submitters, a tremendous opportunity seems to have been missed in a region home to more than half the world's tuberculosis patients. The remarkable successes of the HIV/AIDS community are highlighted in the Article by Alain Vandormael and colleagues. The study provides reassurance that the findings of the landmark HPTN 052 treatment-as-prevention study, done as it was in the somewhat artificial conditions of a randomised trial and among couples in stable relationships, hold true in a high-burden region of South Africa—KwaZulu-Natal—where stable, monogamous relationships are not the norm. The prospective cohort study used robust methods to show that higher antiretroviral coverage at the household level is associated with lower HIV incidence. The authors suggest that the results could encourage individuals to disclose their HIV status to partners, to seek treatment, and to adhere to it—all of which would be enormously welcome in a region where HIV incidence continues to be stubbornly high. Finally, to another event that took place on March 24—a meeting convened by WHO to discuss progress on the eradication of yaws. This neglected tropical disease, which causes non-tender, self-limiting ulcers in the primary stages, but which can lead to deforming bone lesions if untreated, was targeted for eradication by 2020 after a study found that single-dose oral azithromycin was as efficacious as intramuscular benzylpenicillin against the causative organism, Treponema pallidum subspecies pertenue. The meeting participants heard progress reports on mass treatment campaigns from endemic countries and discussed ongoing challenges. One of those is raised by an Article in this month's issue. Oriol Mitjà and colleagues show that, in a yaws-endemic community in Papua New Guinea, more than half the patients presenting with yaws-like ulcers harboured an entirely different organism—Haemophilus ducreyi. Although H ducreyi is also susceptible to azithromycin, its ability to develop resistance must be kept in mind during mass drug administration campaigns. Expecting the unexpected is clearly still the order of the day, even for diseases “as ancient as the mummies”.