A recent renovation of Muhimbili National Hospital, in Tanzania's capital city Dar es Salaam, show that TB care is being moved
into outpatient treatment services. (See "From AIDS to TB") And new funds by the Global Fund to Treat AIDS, Malaria, and TB
will help to further integrate care by funding joint HIV/TB programs, says Saidi Egwawa, national TB and leprosy program manager
at the Tanzania Ministry of Health. That's important because it enables clinicians to better monitor co-infected patients
who may experience interactions between rifampacin, a TB treatment, and nevirapine—an AIDS drug popular in resource-poor settings
because it is donated by Boehringer Ingelheim to pregnant women and their newborn children. Other companies make it available
as a generic.
Invest in infrastructure Like AIDS, TB is so generalized throughout the population that companies can improve the care of patients by investing in
the overarching healthcare infrastructure—and in the process, help strengthen the entire system.
That type of thinking is replacing the disease focus that characterized early AIDS programs in Africa. "PEPFAR [The President's
Emergency Plan for AIDS Relief] has gone into funding the best labs, the best doctors—the best of everything, really—into
centers that have no guaranteed perpetuity after the five-year grant," says Christian Lengeler, a scientist with the Swiss
Tropical Institute. The result: Well-funded AIDS programs outside the government-run system have siphoned health workers away
from hospitals that were already collapsing under the weight of the epidemic.
New company programs must restore, rather than divide, in-country healthcare services. For example, Sanofi-Aventis—a major
producer of rifampacin—is building nine DOTS training centers in South Africa (one per province), in partnership with the
Nelson Mandela Foundation and the government, says Robert Sebbag, MD, vice president of the company's access-to-medicine program.
The program aims to train 50,000 DOTS workers by 2008, and serves as a pilot initiative for future initiatives.
Community-based programs The TB epidemic continues to grow at the rate of one new infection every second. Public-health experts fear that efforts
to scale up treatment will be thwarted by the lack of skilled health professionals, given the daily monitoring required by
DOTS is so resource intensive. Therefore, companies interested in creating treatment programs should investigate alternative
ways of administering drugs, such as self-administered therapy, particularly during the continuation (two-drug) phase of therapy.
"What happens five kilometers beyond the tarmac road?" asks Klaus Leisinger, president and CEO of the Novartis Foundation
for Sustainable Development. "You can go to the last village and find Coca-Cola and plastic combs. As long as this channel
is there, how can we use it for pharma? Instead of bringing patients to drugs, we need to think about ways to bring drugs
A Community DOTS program, which brings compliance measures closer to patients' homes, is being tested in Temeke. Still, even
that type of TB control requires personnel, and personnel have to be paid. Traditionally, funders would rather put their money
into drugs or infrastructure than salaries, but there are signs that some are rethinking that position. The Global Fund, for
example, has thus far dispersed funds only for technical components of TB programs, but Egwawa says it may try to increase
the effectiveness of its grants by also underwriting human resources.
Strong alliances Pharma has already learned some hard lessons when it comes to the developing world. "Pharma thinks the right to health is
aspirational," says Leisinger. "But wake up, no one else in the world thinks that."
Consider pricing, for instance. "There will be pricing pressure whenever drugs are introduced for neglected diseases," says
Sebbag. "We changed the pricing with AIDS, now we are doing the same with TB, and then with malaria."