World AIDS Day 2015 and those tricky '90-(90)-90' targets

Michel Sidibé, the Executive Director of UNAIDS, made an exciting announcement this week. He said:

“The good news is that we now have what it takes to break this epidemic and keep it from rebounding—to prevent substantially more new HIV infections and AIDS-related deaths and to eliminate HIV-related stigma and discrimination.”

This is a fantastic achievement – the result of twenty years' consistent effort, tireless activism and heroic personal contributions. It’s no time for complacency, though, because there’s still a mountain to climb if the Sustainable Development Goal of “ending” HIV by 2030 is to be achieved. But today is surely a moment for HIV activists to both celebrate and be optimistic.

Unfortunately we can never help but compare the successes arising out of such concerted AIDS activism with the corresponding limited progress that’s been made with TB in the same period – and today is no different. Somehow TB has become the permanent poorer relative in relation to its deadly twin (remembering that these two diseases can work with a dreadful synergy, and that the majority of those who die HIV positive in Africa are actually dying of TB).

It’s so easy to forget this. In fact it’s easy to miss it completely because of a crazy but logical rule in the international classification of deaths. For epidemiological expediency it dictates that any human death can only ever be ascribed to one disease, and that, because of the historically-perceived global super-threat of HIV, if you die HIV positive you end up down in the books as dying of HIV even though it’s invariably another opportunist disease that actually kills you. This means that two-thirds of Africans who die each year finally consumed by their tuberculosis infections go down in the international tallies as dying from HIV (and not TB) simply because they lived and died HIV positive.

It’s easy to gloss over the implications of this even if you’re fully aware of them. It can tilt the numbers, for instance, to the extent that officially claims are made that TB deaths have reduced nearly 50% to targeted levels for 2015 when they haven’t. It worries us as a result that even the WHO may be guilty, not just of glossing over the scale of the perpetuating problem of TB deaths, but also of ‘spinning’ their language in their Reports. Here’s the statement, for instance, that the organisation made about TB deaths in relation to HIV/AIDS in its most recent TB Report:

“TB now ranks alongside HIV as a leading cause of death worldwide.”

But it doesn’t actually “rank alongside” it at all! TB is now unashamedly back at the top of the unholy tree of lethal infectious diseases despite its being one of mankind’s oldest enemies, despite its being a disease that’s been curable in most cases for nearly seventy years, and despite the fact that it’s been almost eradicated in most developed countries. In fact the WHO's own numbers show that TB’s estimated annual death-toll now significantly EXCEEDS the death-toll associated with HIV/AIDS – so what’s been a triumph for HIV activists has seen a reversal of fortune for those advocating for tuberculosis. It's all there in the WHO’s own reported numbers: there were estimated to be 1.5 million deaths from TB in 2014 (and we’d suggest quite probably a lot more..) whilst there were 1.2 million deaths logged for HIV/AIDS. (HIV was killing more than 2 million a year in its heyday so whilst 1.2 million annual deaths is still a huge number and still a tragic waste of lives, this should be recognised as huge progress. Tuberculosis, on the other hand, has being pretty consistently killing the same amount of human beings throughout this same period year on year.)

This simple graphic illustrates what’s been shaping up for years. In this illustration the middle section shows those co-infected with both diseases who often only get reported in the HIV numbers.

So we suggest that the WHO’s news about TB in October’s Report would have been better announced as follows:

“TB, mankind’s oldest bacteriological enemy, is now once again humanity’s most lethal infectious killer”.

The new '90–90–90' targets

Last year UNAIDS adopted a new and rather catchy ‘90-90-90’ slogan as a part of their plan for ending HIV. According to this plan, by 2020 90% of all people living with HIV will know their HIV status; by 2020 90% of all people with diagnosed HIV infection will be receiving sustained antiretroviral therapy; and by 2020 90% of all people receiving antiretroviral therapy will have achieved viral suppression. (And what's more, by 2030 these same targets are intended to be ramped up to 95-95-95 driving HIV right into submission.)

Once again TB advocacy was looking outclassed and left behind, but right at the end of last year fresh efforts were made to match the undeniable ambition of these targets for HIV. In November in Brasilia the Ministers of Health from Brazil, Russia, India, China and South Africa announced almost identical commitments regarding tuberculosis at their BRICS Health Ministers Meeting.

They approved a co-operative plan that would include a common approach to universal access to first line tuberculosis medicines for all people with TB (not just in BRICS countries, but also in low- and other middle-income countries as well).

Perhaps a little unimaginatively they similarly called it ‘90-(90)-90’ (just a couple of brackets encouraging us to spot a difference.)

By this plan by 2020 90% of TB patients will be being diagnosed and started on first line drug treatment, 90% of the most vulnerable groups will be being screened, and a success rate in those receiving treatment of 90% will be being achieved. Furthermore they reckoned that meeting these targets will help see TB ended by 2035.

These targets for TB were originally suggested by Dr. Aaron Motsoaledi (who’s not just Chair of the Stop TB Partnership but also Minister of Health for South Africa) back in October 2014 at the Union Lung Conference in Barcelona. This year's same Union Conference is being this week in Capetown, with special store being placed in launching the Partnership’s Plan for TB for 2016-20 with the 90-(90)-90 targets at its very heart. In fact, by coincidence, this Plan and its targets have been officially endorsed today (on World AIDS Day) by its delegates.

The BRICS ministers also agreed to cooperate on scientific research and innovations on diagnostics and treatment, including in relation to drug-resistance. They identified sharing technologies, identifying manufacturing capacities and TB financing as key priorities. But it’s the drug-resistant component that must now be the make-or-break factor within their ‘nineties’ targets, but the truth (at least as far as we can see it) is that they don’t allow for drug-resistance at all.

Getting 90% of drug-susceptible TB cases diagnosed and on treatment is a big ask for sure, but it’s still achievable with concerted efforts given that currently 68% are believed to already be being found and treated. But with MDR-TB this same case detection rate is just 25% at best (and we’d suggest that even this percentage is optimistic). Anyone who seriously believes that this percentage can be improved nearly fourfold in as many years knows nothing about the challenges of diagnosing MDR-TB.

Meanwhile a 90% treatment success rate for drug-susceptible TB is even more achievable given that it’s already reported that an 87% success rate is being achieved. But with MDR-TB the related success rate is just 50% - and with XDR-TB it’s a terrible 25%. There’s little or no chance that these targets can be achieved in the timescale allotted for DR-TB.

There are possible knock-on consequences of these ‘nineties’ targets for TB. They're worrying and shouldn’t be underestimated. Individual health ministries are being increasingly pressured to do more to meet the targets set for them. If national TB programs are then put under the cosh to meet these targets they’ll do the obvious and concentrate almost all of their resources on achieving them – because otherwise they’ll be judged accordingly and may well lose their donor funding. But if they do so they’ll almost certainly do it at the expense of any existing MDR-TB problem that they have (because treating MDR-TB is so much more expensive and more challenging). In other words, meeting the very targets that are being seriously mooted to help end TB may paradoxically cut the drug-resistant component loose for the second time in twenty years.

What makes this all the more perplexing is that it was the ministers of the BRICS countries who came up with these targets, because four out of five of them are well-recognised to have drug-resistant TB epidemics that are the worst in the world. South Africa’s epidemic is well recognised to be out of control (though at least its extent is well recognised); China’s is known to be proportionately dangerous and is also reported to be occurring at frightening rates in newly infected cases; Russia’s (along, it should be added, with all of the former Soviet oblasts) DR epidemic is well entrenched and chronic (Mario Raviglione, the WHO’s TB czar, has euphemistically suggested that “something is not going well there”); and India’s is almost too terrifying to consider having been officially ignored and underestimated for far too long. Of the BRICS countries only Brazil seems to have escaped the curse of MDR-TB.

The fact that these five countries not only generally fund their own TB programs but also generate 25% of global GDP and have significant research infrastructure and capacity at least gives us cause for hope, but even Dr Motsoaledi must accept that his own country’s budgets for fighting MDR-TB (which are certainly more generously allocated than most) aren’t containing the problem and are already insufficient.

Somehow HIV trumps TB every time. It trumps it in the advocacy stakes. It trumps it in the resources stakes. It even trumps it in the coherency stakes. There’s enormous catching up to be done and we’re probably going to need the help of the HIV community to do it.

In contrast, the only thing that TB manages to trump HIV in is in its inherent complexities. There's unquestionably a long hard road ahead before we can claim we’re defeating this disease, and it's one which we're sure needs to be navigated not with catchy soundbite targets but with immense determination and unprecedented creative intelligence.