In 2008, 3.6 million women developed TB and approximately half a million died. Yet little attention is paid to the unnecessary suffering and death of these women and the impact it has on them and their families.
Research shows that women who develop TB disease are more likely to die from it than men, suggesting that either TB impacts women differently on a biological level, or that women are not properly diagnosed and treated.  Women who are infected with the TB germ are also more likely than men to develop infectious TB disease.
Women’s susceptibility to TB in low-income countries is often linked to their lower socio-economic status, reduced access to economic resources, lower education, and fewer opportunities to access relevant health information as compared to men. As a result, women tend to use less qualified health services or may delay accessing diagnosis or care until the disease is severe. Malnutrition and food insecurity can exacerbate the risk of TB disease; other threats such as rising tobacco use and diabetes among women, can also mean an increasing burden of TB. Studies have also shown a strong association between TB of the lungs and women who cook indoors with biomass cooking fuels, such as wood or cow dung. It is thought that cooking smoke impairs the respiratory system’s ability to resist TB infection, or in the case of women who are already infected, it may impair the immune system’s ability to fight off the development active TB. Pregnant women are at particular risk. Receiving a late diagnosis of TB puts a mother at four times the risk of dying during childbirth, 5 and also places their infant at increased risk.
To add to all of this women in low income countries bear the highest amount of stigma with respect to TB. The fear of discrimination and rejection from their own families and wider community often negatively influence women’s decision to either seek medical attention for tuberculosis testing or in disclosing their TB. In some communities, women may be forced into divorce, sent back to their parent’s home, or if unmarried, have fewer chances of finding a marriage partner. Children are often forced out of school to care for other family members, or need to work to replace their mothers lost income.
It is clear that women are particularly vulnerable from TB, and that investment is needed to provided much earlier, and better, diagnosis and treatment. Although there has been considerable progress made in reaching populations through widespread roll out of DOTS, TB will never be eradicated unless the most vulnerable groups, including women, are reached.
However, a major barrier to progress in the fight against TB is that the world still lacks adequate tools for diagnosis and treatment. For over 50 years tuberculosis patients have been treated with essentially the same therapeutic regimens. The only licensed vaccine against TB, the BCG, is more than 100 years old and does not prevent pulmonary TB in adults (only in children), which is the most common and infectious form of the disease.
Diagnosing TB, even the most common form, is still not straight forward. For pulmonary TB, a patient has to cough up sputum, and a lab technician needs to smear it on to a slide, staining it and then looking under a microscope for disease-causing bacteria. The method calls for skilled staff (often in short supply in remote areas of low income countries with weak health systems) and many of the poorest people fail to access TB diagnosis because the closest lab is too far away. This method of diagnosis is also difficult for sick children, who struggle to produce the sputum necessary, and often produces falsely negative results in people living with HIV – those most vulnerable to becoming sick and dying of TB. Also, it is possible to get TB anywhere in your body, and for those patients, diagnosis is even more difficult and costly.
Current treatment regimes for TB are too long, with a full course of treatment prescribed for a minimum of 6 months. The standard treatment is a combination of 3 or 4 antibiotics for a period of 2 months, with 2 antibiotics for a further 4 months. The current treatment regimen works for active, drug-susceptible TB — as long as patients complete the full six- to nine-month treatment, ideally under direct observation by a healthcare worker or community member. However, adherence to this treatment is challenging, particularly as patients begin to feel better and no longer want to take the burdensome average of 130 doses. There is no specific paediatric version, so for children, TB drugs are particularly hard to take. If treatment is not completed, a patient may develop drug-resistant TB (MDR-TB) which is much more difficult and costly to treat. Extra-drug resistant strains of the disease have been found, and these are untreatable with any existing antibiotics.
Also, the current TB drug regimen is not compatible with certain common antiretroviral (ARV) therapies used to treat HIV/AIDS, requiring a change in regimen to avoid drug-drug interactions. Even where TB drugs are made available free to those who need them, the length of treatment places an undue burden on patients, due to frequent visits to health clinics, additional transport costs, and lost work hours.
With the vast majority of TB patients concentrated in the world’s poorest countries, there has traditionally been little incentive for the private sector to invest in the major research and development costs necessary for new TB medicines. A report released in 2009 by the Treatment Action Group (TAG) and the Stop TB Partnership found that research funding for tuberculosis increased just 7% between 2007 and 2008. Global investment in TB research and development has decelerated rather than growing in the three years since The Global Plan to Stop TB 2006-2015, was issued. Between 2006 and 2007 investment rose by US$56 million–to a total $474 million. However between 2007 and 2008 investment rose by just $36 million, to $510 million. Funding needs for TB R&D are estimated at around US$2 billion, but funds are no forthcoming from national governments. MSF recently reported that European countries’ contributions towards TB R&D are particularly weak.
In January this year, the Bill and Melinda Gates Foundation announced a commitment of $10 billion over the next 10 years to the research and development of new vaccines. However, governments now need to step up to meet this investment into all new tools to diagnosis, treat and prevent this disease.
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