In 2014, for the first time ever, tuberculosis (TB) caused more deaths worldwide than HIV/AIDS making TB the world’s biggest infectious disease killer. TB killed 1.5 million people in 2014, ahead of HIV/AIDS, which was responsible for 1.2 million deaths in the same year. The WHO Global TB Report also revealed that India continues to be the country with the highest TB burden with nearly one-fourth of the global burden.
Through the adoption of the End TB Strategy, India has committed to reducing the number of TB deaths compared with 2015 by 95%. The challenges India faces are daunting but certainly not unachievable. An exemplary comparative case-study to learn from would be that of our response to the HIV/AIDS epidemic.
India’s commendable performance in its HIV/AIDS response was the result of a well-structured, swift and targeted plan. In short, the level of government prioritization was aligned with the magnitude of the challenge. Apart from allocating the necessary budgets, the government also introduced supportive policies such as the exemption of import duties and capping of prices for HIV drugs and diagnostics, which decreased their prices and ensured access to all.
One of the major challenges faced by India’s Revised National Tuberculosis Control Programme (RNTCP), is the recent upsurge of drug resistant TB (DR-TB) cases in some areas (e.g. Mumbai), which are more difficult and expensive to treat. It is estimated that 71,000 drug resistant TB cases emerged in 2014 . In reality, the number of drug resistant TB cases might be even higher, since private sector providers do not always notify and register these cases to the RNTCP. Considering the large burden of DR-TB, it is evidently vital to consider offering ‘Universal Drug Susceptibility Testing (DST)’ across the country,all patients with TB, to ensure that they receive accurate treatment, based on drug-resistance information.
Need for Universal DST
In a study conducted by the Indian government, it was found that using the GeneXpert (a cartridge-based nucleic acid amplification testing machine or CBNAAT) molecular test, which is a WHO-recommended diagnostic tool, as an initial diagnostic test for TB in public health facilities, increased the number of rifampicin-resistant TB case notification by ‘fivefold’. The fivefold increase can be attributed to the fact thatthe CBNAAT was used for testing drug resistance in all persons with suspected TB, rather than a select few at high risk of drug-resistance.
The study reaffirms concerns of experts regarding the underestimation of the number of DR-TB cases in India and paves the way for the establishment of ‘Universal DST’ which is one of the most important directives of the End TB Strategy.
Considering that a majority of the Indian population seeks care in the private sector, we must recognize that in order to promote Universal DST, both the public and private sectors need to be able to provide good diagnostics at an affordable price. Delays in diagnosis and detection can have grave consequences including the transmission of the disease to others.
In an attempt to provide these tests at affordable prices, a network of private laboratories in India called Initiative for Promoting Affordable and Quality TB Tests (IPAQT) was established. IPAQT provides the cheapest CBNAATtest at a fixed price of Rs. 2000 compared with an average of Rs. 3,490 in the rest of the private sector in India. Through the 115 accredited private laboratories under IPAQT,that receive concessional pricing for WHO recommended tests such as the CBNAAT, there has been an increase in the number of people accessing the highly accurate diagnostic CBNAAT test from 15,190 people who took the test between March and December 2013, to 1,31,440 tests in 2015.
As was the case for HIV, the government should also consider waiving the high import duty levied on the procurement of TB diagnostic machines and their consumables. At present, the government exempts several critical diagnostic tests and life-saving drugs for HIV from paying import duty. The government could similarly consider waiving import duty for all TB tests that are approved by WHO or RNTCP. It is however important to ensure that such benefits are transferred to the patient and mechanisms such as IPAQT are necessary to ensure this.
Prioritizing TB Control in India
On an average TB kills over 2 lakh Indians every year. For a disease that is curable, this is unacceptable. If we truly want to succeed in ensuring our people have access to their right to a healthy and TB-free life,we need to prioritize TB control, allocate the necessary resources and create a policy framework that supports the overall goal of reducing the burden and mortality of TB.
Our policies should also be supportive rather than punitive of the choice patients make when they seek care in the private sector. It is time for the government and the private sector to develop and implement a clear cross-sectoral approach to combat the disease keeping the patient’s rights and their well-being at the centre of our plans.
(The author Dr Madhukar Pai is, MD, PhD. Professor, McGill University. Associate Director, McGill International TB Centre)
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