“We spent hundreds of rupees in private health clinics to trying to cure my tuberculosis, but none of the medication worked. The treatment included daily painful injections with lots of side-effects like vomiting, fatigue, loss of appetite… and sometimes even suicide,” says Rabiya, a 27-year-old woman with extremely-drug-resistant tuberculosis (XDR-TB). She is now a patient at the Doctors Without Borders/Médecins Sans Frontières clinic in Mumbai.
Around the world, according to the most recent World Health Organization (WHO) TB report released in 2019, an estimated 10 million people fell ill with TB in 2018, with India bearing the largest share of global TB burden (27 per cent). Multi-drug-resistant TB (MDR-TB)  is a very difficult disease to treat. For many years MDR-TB patients and their doctors have had to resort to long treatment regimens involving toxic medications and staggering treatment cost. For a full treatment cycle of between 6 to 30 months, the regimen can consist of daily painful injections for up to six months, more than 14,000 pills for a length treatment compounded with severe side-effects and uncertain positive treatment outcome – only half of the people with MDR-TB get cured.
 MDR-TB is TB that is resistant to at least two of the most effective TB drugs, isoniazid and rifampicin. These drugs are considered first-line drugs and are used to treat all persons with TB disease.
In 2012 and 2014, after almost 50 years of using existing treatments two new TB drugs, bedaquiline and delamanid, were approved by international regulation authorities and included in WHO guidelines on DR-TB management. The drugs offer safer, shorter oral treatments with fewer side-effects and better cure rates.
Rabiya was referred to the MSF clinic in October 2018 and, based on her drug susceptibility testing  results, she was started on a treatment regimen that included delamanid and bedaquiline. After a few months, Rabiya started feeling better and her life returned to normal. As well as the physical improvements, she also felt stronger psychologically. “I have a four-year-old daughter and for so many years I have been keeping her away from me, as I feared transmitting my TB infection to her. It is difficult to isolate your child when they need you the most… Now I can play with her, hug her, and I want to ensure that she has proper schooling.”
 Drug susceptibility testing means testing to find out if a person has got DR-TB. It involves finding out which drugs the TB bacteria in their body are sensitive to.
“My last visit to clinic was on 12 March and my next monthly appointment is scheduled 12 April, which falls within the lockdown period,” says Rabiya. “Though the government has said that essential health services will remain open, I know that someone like me will face enormous challenges with no public transport and police restrictions on the movement of private vehicles. Without support services, I am worried. Who will do my blood test, my ECG, my physical check-up, and how will I get my drugs? I have come a long way with my treatment, after so much of failure. I have not missed a single pill and just hope that the outbreak doesn’t have negative impact on my health, my treatment continues and I can be cured.”
This worrying situation will become even more grave if diagnosis and treatment for TB are interrupted, as their infection might develop to a stage where it is even more resistant to TB drugs than their current one. While observing national and state level COVID-19 guidelines, MSF clinics have so far ensured continuity of care for their patients, adapting their ways of working to protect patients and medical personnel while providing essential services. MSF is supporting the National TB Elimination Programme (NTEP) and the WHO on strategies to maintain continuity of essential services – prevention, diagnosis, treatment and care – for people living with TB and DR-TB during the COVID-19 pandemic. MSF welcomed the decision of the NTEP to keep its TB services operational. However, the current stringent lockdown rules make the strategic positioning of personnel and supplies very difficult and MSF is calling for pragmatic measures to allow for the continuity of health services.
MSF praises the Indian Ministry of Health and Family Welfare for its roll-out of community-supported testing and treatment using oral TB drugs for MDR-TB. In light of the COVID-19 outbreak, MSF calls on the NTEP to accelerate the implementation of its programme countrywide. This will reduce the number of trips patients are required to make to health facilities, making it easier for them to adhere to social distancing infection prevention protocols and ensuring both patients and staff are protected.
“Given the high risk of accelerated co-infection with novel coronavirus among TB and HIV patients, and to prevent an increase of deaths from these underlying conditions, all efforts should be undertaken to increase voluntary testing among people living with HIV and TB, and to isolate people with confirmed or suspected COVID-19 to avoid transmission to others. We critically need global solidarity to overcome this pandemic, by protecting our patients, our health workers and our communities,” says Dr Farah Naz Hossain, Medical Coordinator for MSF India.