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Posts Tagged ‘Lancet’

Today, The Lancet launched an impressive new series of articles on the global tuberculosis epidemic, which claims 1.8 million lives every year. The Lancet articles note that TB is a leading cause of death in people in the most economically productive age-groups. The series highlights scale up of treatment and diagnoses, drug-resistant TB, and HIV/TB co-infection, as well as the huge funding gap for TB control and research and development, with many countries struggling to deliver basic diagnostic and treatment services.

The authors of one lead article conclude: “Acceleration of the present decline towards TB elimination will need invigorated actions in four broad areas: continued scale-up of early diagnosis and proper treatment in line with the Stop TB Strategy; development and enforcement of bold health-system policies; establishment of links with the  broader development agenda; and promotion and intensification of research.”

With the unveiling of this series, we spoke today with Zhenkun Ma, Ph.D., Chief Scientific Officer for the TB Alliance, who authored this article focused on TB drug development and the promise of new medicines to greatly improve TB treatment.

Q: You point to the results of a modeling study that suggests the combination of a 2-month treatment regimen that cures 95% of MDR tuberculosis, a better TB diagnostic tool, and a joint pre-exposure and post-exposure TB vaccine could potentially reduce the incidence of this disease by 71% by 2050. But that seems like a very tall order. How realistic is it that we can achieve those goals and what will it take to get there?

A: I think it’s very feasible. We have a very strong pipeline. On the drugs front, the goal of achieving a 95 percent cure rate for drug-resistant TB with new drugs is very doable. Right now, there are 10 drugs in clinical development, and the majority—six new drugs—belong to novel drug classes with new modes of action, new mechanisms. Bacterium has never seen these compounds before. They work differently from old drugs and are able to overcome drug-resistant forms of TB.

Four of the drugs in the pipeline are currently being used to treat other bacterial infections. We are in the process of figuring out how to best use these to treat TB. Because of these developments, I think it’s very feasible to achieve significant reductions in TB incidence.

Q: One problem you highlight is inadequate clinical trial capacity to test new regimens for TB treatment. Can you elaborate on that? Why isn’t there enough capacity, how inadequate is it, and what will it take to get to full capacity?

A: TB has its worst impact on developing countries. The places you have TB patients, generally, do not have the capacity to conduct modern clinical trials. Most parts of Africa, for example, simply don’t have the laboratory capacity required to support registration trials. And the places we are able to conduct registration trials, you simply don’t have enough patients with TB. So that’s the challenge and the disconnect. Funding is really the key to support capacity building and clinical capacity strengthening.

Q: What research is currently underway to improve pediatric treatment of TB?

A: Pediatric TB has largely been ignored. It’s a major challenge because it’s hard to do. We don’t have very good diagnostic tools. It will take a lot of research work to figure out how best to detect TB and monitor the efficacy of treatments in children. However, we are committed to developing drugs that can be used for all patient populations.

Q: The funding shortfall for TB research is huge. It has long been a neglected disease. What do you think it will take to change that?

A: Clearly the funding gap is huge. MSF recently reported there is a 75 percent gap in the funds needed for TB research and development. A lot of people think TB is simply not a problem anymore. The Lancet articles are a great opportunity to point out that TB is still a devastating global problem, with 2 million people dying from TB and more than 9 million new cases of TB occurring each year. This is really a massive global problem and requires people to pay more attention and invest more resources. We need all the stakeholders to allocate more resources to support TB drug development.

For more info, here’s a link to the Lancet press office and below is the Lancet press release on the Series, which has descriptions and links for each article: (more…)

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The Lancet today published a new analysis of maternal mortality data, in which the authors document greater progress in reducing maternal deaths than previous examinations. They also highlight the role of HIV in preventing even more significant gains in saving mother’s lives.

The authors estimate there were 342,900 maternal deaths globally in 2008, down from about 526,300 in 1980. Subtract HIV from the equation, they write, and there would have been 281,500 maternal deaths in 2008. The on-the-ground implications: more pregnant women and new mothers should be given access to ARVs.

“Our analysis, in line with previous studies, draws attention to the important adverse effect of the HIV epidemic on the MMR [maternal mortality ratio], especially in east and southern Africa,” write Dr. Christopher Murray, of the Institute for Health Metrics and Evaluation at the University of Washington, and colleagues. “In the absence of HIV, progress in sub-Saharan Africa in reducing the MMR would have been much more extensive than we recorded. The counterfactual analysis of the MMR without HIV-related deaths has important implications for intervention policy. The set of interventions for dealing with HIV infection in pregnant or post-partum women would include access to antiretroviral drugs, which is not part of the set of maternal health interventions targeting women who are HIV negative.”

In an accompanying editorial, the Lancet writes that “HIV has been a major cause of paralysis” in improving maternal mortality and this study exposes “the intimate connection between HIV and maternal health.”

Hopefully this connection will not be lost on key policymakers, as maternal mortality gets increased attention from the White House and others in the U.S. government.

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Most global AIDS advocates would agree that PEPFAR is at a critical juncture, mainly because of fears that Congress and the Obama administration are set to pull back from the program in favor of a new push on maternal and child health and health system strengthening. But in an interesting commentary in the Lancet today, Peter Navario, a one-time manager of a PEPFAR-funded program, argues that PEPFAR’s biggest “liability” is its inadequate focus on patient retention and adherence.

Navario writes that concerns about adequate funding and leadership are “unlikely to derail PEPFAR,” a statement could provoke sharp debate given the widespread concerns that proposed increases for PEPFAR, from the White House and Congress, could stall the program. But his second point might be more well-received.

Navario argues that PEPFAR needs to undergo a “paradigm shift” from “emergency initiative (i.e. short-term) into a chronic care program for developing countries.” He notes that PEPFAR’s biggest success–starting 2 million people on treatment—“also means keeping 2 million people on treatment for years (and hopefully decades).”

On that front, he says PEPFAR has not done very well so far, citing a study in sub-Saharan Africa which showed nearly 40 percent of patients were no longer on treatment after 2 years.

Navario’s commentary comes as the curtain rises on the 2009 International AIDS Society conference in Cape Town, where fears run deep about a possible global pullback on AIDS funding.  The IAS is live blogging from the conference (and we will be too) and kicked off today with a series of interesting posts about everything from the G8 summit to AIDS & politics in South Africa. Stay tuned for more news as the conference gets under way in the coming days.

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The long-simmering debate over the impact of disease-specific programs on health-system strengthening may have just reached a boil.

Today’s Lancet features an in-depth exploration of the impact of global health programs, particularly those aimed at tackling HIV/AIDS, tuberculosis and malaria. The debate has gained steam in recent weeks, since the White House announced its new global health initiative that appears to step back from programs like PEPFAR in favor of broader health-system strengthening.

The crux of the issue is summed up this way in one of the Lancet articles: “Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets.”

(more…)

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A new study suggests that HIV infected patients should start antiretroviral treatment earlier.

 

Here’s the editor’s note accompanying the article in today’s online version of the Lancet:

 

“When to start antiretroviral treatment has been a problem for physicians dealing with patients with HIV infection. Most commonly the decision is based on CD4 counts, but just what is the best CD4 count for the start of treatment has not been clearly defined. This paper pools data from a number of large patient cohorts and provides the strongest evidence available for when to start HAART. These data should inform, and change, treatment of HIV patients.”

 

And here’s a link to the Lancet piece:

 

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60612-7/fulltext

 

Reuters news service also reported on this study. Click here to read their story, which says, in part, “An analysis of more than 45,000 people with HIV in Europe and North America found they were 28 percent more likely to develop full-blown AIDS or die if they deferred treatment until the point currently recommended in many countries.”

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