Target for good health-related quality of life post-treatment is needed for TB, says Union article

The global health community must include a target to ensure that 90 percent of all people successfully completing treatment for TB can have a good health-related quality of life, says a Union article in the December issue of the International Journal of Tuberculosis and Lung Disease (IJTLD).

This should be included in the 90-90-90 TB diagnostic and treatment targets, first introduced in the Stop TB Partnership’s Global Plan to End TB (PDF 7.3KB) in 2015 (an updated Global Plan 2018-2022 was released this week). These people-centred targets include: reaching 90 percent of people affected by TB, reaching 90 percent of key populations and achieving 90 percent TB treatment success.

These testing and treatment targets were based on a similar set for HIV/AIDS launched in 2014, specifying that by 2020: 90 percent of all people living with HIV will know their status, 90 percent of all people diagnosed with HIV will receive sustained antiretroviral therapy and 90 percent of all people receiving antiretroviral therapy will have viral suppression. A ‘fourth 90’ for HIV was proposed in 2016 to “ensure that 90 percent of people with viral load suppression have good health-related quality of life.”

The Union article calls for the addition of a ‘fourth 90’ to TB diagnostic and treatment targets on the basis that, for many, successfully completing anti-TB treatment or being cured of TB, does not necessarily mean a good healthy quality of life away from the health care system.

TB is associated with a number of co-morbidities, some of which require ongoing access to health care, medication and laboratory analysis. The most common examples concern people living with HIV and/or diabetes, and obstructive and restrictive lung disease that either pre-existed or developed as a result of TB. Further comorbidities, conditions and determinants include silicosis, chronic pulmonary aspergillosis, malnutrition, cigarette smoking and excess alcohol, and are risk factors that can pervade post-TB treatment. 

Although anti-TB treatment can be effective, it is not benign. For example, second-line injectable agents used for treating multidrug-resistant TB (MDR-TB) can often result in progressive and permanent hearing loss. Despite the move to all oral regimens there remain other drugs used for MDR-TB that have long lasting effects that persist after treatment stops and as such TB survivors will continue to need support and treatment.

In addition, the prevalence of mental illness among people with TB is high and can continue after successful completion of TB. Mental illness can stem from stigma, discrimination, isolation, poor social support, and the adverse effects of medication. Other common risk factors shared with TB such as poverty, homelessness and substance abuse may also continue after successful TB treatment.

The above-mentioned co-morbidities, side effects of anti-TB treatment, and mental health disorders all mean a considerable proportion of people affected by TB need help and support after the treatment is completed.

It is important that co-morbidities are identified during TB treatment, and where relevant, persons are formally referred back to HIV or diabetic clinics for ongoing quality assured care. Person-centred services such as cessation support, respiratory function assessments, definitive diagnoses of respiratory diseases, and ongoing support and care for those with mental health disorders or deafness, all need to be fully integrated with a focus on Universal Health Coverage.

The article concludes “The ‘fourth 90’ for TB provides a specific indicator that assesses how well integration has occurred and is perfectly aligned with the ‘fourth 90’ proposed for HIV/AIDS. It reminds the healthcare workforce that the ticked outcome ‘successfully treated’ means that their job is not yet done and an extra effort is required to help the people in their care acquire and maintain a good health-related quality of life.” 

The full article, ‘Should we consider a “fourth 90” for Tuberculosis?’ was published in the December issue of the IJTLD and is available to Union members. For further information about becoming a member of The Union, please consult theunion.org website.

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