SOUTH AFRICA: TB plan has a gap between talk and action

Health Minister Manto Tshabalala-Msimang opened South Africa's first national tuberculosis (TB) conference this week with some welcome good news: her department is to acquire technology that will reduce the time it takes to diagnose drug-resistant TB from as long as four months to less than a week.

South Africa is struggling with a rising incidence of multidrug-resistant (MDR) TB, a form of the disease that does not respond to standard treatment with first-line drugs. The difficulty of diagnosing MDR-TB using the current method of growing cultures in a specially equipped laboratory has meant that many patients infect countless others or die before their results are known.

Although 7,369 cases of MDR-TB were diagnosed in 2007, according to health department figures, it is likely that many more cases went undetected.

The new diagnostic test, which uses a molecular method known as "line probe assays", was developed by the World Health Organisation (WHO) and the Foundation for Innovative New Diagnostics and tested in a South African field trial conducted by the Medical Research Council and the National Health Laboratory Services.

According to a WHO statement, the trial produced results encouraging enough for the DNA-based tests to be rolled out in 16 countries with a high TB burden, but delivery of the new equipment and training staff in how to use it would take place over the next four years. Lesotho is so far the only country equipped to do the tests.

Tshabalala's speech skimmed over the grim figures behind South Africa's TB burden, among the highest in the world, and focused on the small gains made in the last two years: a one percent drop in national TB infections between 2006 and 2007, and an increase in the national cure rate from 55 percent in 2005 to 63 percent in 2006- still way below the 85 percent cure rate recommended by the WHO if goals for reducing the global TB burden are to be met.

"We are moving in the right direction," Tshabalala insisted, "and with the support of our stakeholders ... we shall be able to reach our targets."

Not everyone at the conference shared the minister's optimism. "There seems to be some sort of rosy lens that the ministry is trying to put on TB," said Paula Akugizibwe, a TB/HIV training and advocacy officer with the AIDS and Rights Alliance of Southern Africa (ARASA), a regional partnership of non-governmental organisations, based in Windhoek, Namibia.

"It's important to highlight achievements, but we can't let that obscure the pressing challenges," she commented.
The emergence of MDR-TB is widely recognised as the result of failures in the country's TB control efforts. Drug resistance is usually the result of TB patients not completing their six-month course of first-line treatment. TB is curable, yet it is South Africa's leading natural cause of death and one of the main factors behind the country's declining life expectancy.

Lesley Odendal of the AIDS lobby group, Treatment Action Campaign (TAC), presented a critical analysis of the government's 2007 to 2011 strategic plan for TB, in which she identified insufficient budget allocations, a failure to adequately address critical issues like drug supply and infection control, and a lack of detail on how to implement the goal of integrating TB and HIV programmes as some of the plan's weaknesses.

"There's a lack of accountability structures, decisiveness and sense of urgency," she told delegates.

National Treasurer of the TAC and Executive Director of the AIDS Law Project, Mark Heywood, went further: "We have a gap between rhetoric and lack of action," he said.

He described the strategic plan as "an enormous step forward", but worried that it would be no more than a wish-list if the government did not back it up with political leadership and resources.

"The plan will fail," he said, unless the government takes a number of steps, including identifying and implementing emergency measures, coordinating a massive information campaign, and developing a human-resource plan for TB.

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