On the outskirts of Batumi, a beach town on the Black Sea popular with Georgians, Russians, Turks and Israelis, Teimuraz Ajiba sits down to pose for a portrait. We are outside the city’s worn-down tuberculosis (TB) hospital. Ajiba has a wide smile and a strong, wiry frame. He says he feels better, despite his treatment being paused while his liver recovers from the toxic drugs - and despite TB being just one of his problems. He also suffers from hepatitis B, hepatitis C, skin cancer and HIV.
To complicate matters, his TB is ‘drug-resistant’: for Ajiba, the standard antibiotics no longer work. Multidrug-resistant TB or ‘MDR-TB’, as it is known, requires up to two years of pills and injections. This treatment is much less effective, using so-called ‘second line’ drugs with often harsh side effects - such as deafness, psychosis, nausea and, in his case, liver toxicity that aggravates his hepatitis.
Ajiba’s case is not as rare as you might think. MDR-TB sufferers are often afflicted by coinfections. The disease tends to affect people with weak immune systems. In many cases, it privileges marginalised communities.
TB spreads more easily in places like prisons, slums or refugee camps, where appropriate treatment is rarely available. In turn, inadequate treatment - when drugs are poor quality, or not taken in the necessary amounts, intervals or combinations - allows the TB bacteria to learn to fight back.
A person who develops this drug-resistant form risks passing it to others. The world should tackle MDR-TB for the sake of patients, but also for preventive purposes: according to World Health Organization (WHO) estimates, there are half a million new cases of MDR-TB each year, and TB is now the leading infectious killer worldwide, killing almost 1.8 million people last year.
‘No one took it seriously and it got worse and worse’
In Georgia, TB emerged as a major public health problem following the breakup of the Soviet Union. The 1991 civil war that followed Georgia’s independence led to a large number of internally displaced persons and a breakdown in health services. Infectious diseases like TB became much harder to control. MSF first began treating TB in the country in 1999 and, noting a rise in drug-resistant cases, refocused its efforts on MDR-TB in 2007.
Among Georgians, TB is often regarded as a prisoner’s disease. There is some truth to that.
Otar Gujejiani was imprisoned in 2009. “No one took it seriously there and it got worse and worse,” he explained. Following his release he was sent to Abastumani, a grandiose century-old sanatorium in the mountainous Meshketi region known for its clean, brisk air.
The sanatorium continues to fulfil its original role today, though only 70 of its 200 rooms are in a fit state to host patients. MSF has worked here since 2014.
In Abastumani, several of Gujejiani’s fellow patients shared a similar experience.
Kale Mantkava was first diagnosed with TB in 1987 and underwent a first treatment, unsuccessfully. “I was jailed in 1993”, Mantkava continued, explaining that he underwent a second, 18-month treatment for his disease while in jail. By then, he was drug-resistant.
He was released in 1997 and felt no symptoms for almost 15 years.
But this treatment, it turned out, was no more successful. In 2011, the cough returned and his lungs continued to degrade.
TB used to be called ‘consumption’, a name evoking its slow, grinding grip on the human body. “At the start, most patients think they can take it easy as they don’t have severe pain. But they don’t know how far it can go,” Mantkava said.
‘A dragon with nine heads’
As if the constant fever, blood-tinged cough and creeping weakness were not enough, it is the drugs - not the symptoms - which patients often fear most. A typical TB requires a six-month treatment with four antibiotics. But MDR-TB is a different animal.
Because those ‘first line’ antibiotics no longer work, doctors must resort to old, toxic and less effective drugs the bacteria have never encountered: the medical equivalent of ambushing the enemy with blunt tools.
First there are the pills: a patient may take up to 14,600 over their treatment. The side effects vary from person to person, but all suffer.
Then, the needles. In many cases patients receive painful injections every day. They are also likely to undergo months of twice-daily, hour-long infusions. Georgia does not have the infrastructure to treat patients at home, so patients must visit the hospital at least once a day.
Many patients spend their day travelling to and from the hospital. In the time they have left, they recover from the infusions themselves, which leaves them exhausted and with side effects like rashes, nausea, or a deafening ring in their ears.
Asked how she counsels her patients at the onset of such harsh treatments, Dr. Iza Jikia, who works at the National Centre for Tuberculosis and Lung Disease in Tbilisi, responded:
“I would say it is like a dragon with nine heads. If we miss even one it will develop again. For this you need to be strong”.
Hope for new treatments: “Now I feel so good”
A couple of years ago, the small world of TB research experienced a breakthrough.
After almost five decades of neglect from the pharmaceutical industry, two new drugs, bedaquiline and delamanid, were unveiled in short succession. (These are developed by Janssen Pharmaceutica and Otsuka Novel Products GmbH respectively.)
And since 2015, Georgia has been one of the countries hosting the endTB project, a partnership among Partners In Health, Médecins Sans Frontières, Interactive Research and Development, funded by UNITAID.
The project aims to provide early access to bedaquiline and delamanid to 2600 patients in 14 countries, including Georgia.
In late 2016, Georgia is set to become the first of five countries participating in endTB’s clinical trial, where 750 patients will be given pared-down treatments designed to maximise the new drugs’ potential - while minimizing the old, toxic antibiotics.
The aim is to find shorter, less toxic and more effective treatments. The early results with bedaquiline and delamanid leave doctors in Tbilisi feeling optimistic.
As Dr Nino Dzidzikashvili explained,
“there are more efficient medicines, new schemes available nowadays. The treatment conditions are better than before. And we expect even more positive results.”
The results of endTB will help expand access to these new drugs and promote better treatments worldwide, by influencing national and global guidelines.
Currently less than 2% of MDR-TB sufferers worldwide can hope to access bedaquiline or delamanid. In Georgia so far, the project has supplied new drugs to more than 200 patients.
But these words and portraits from endTB patients may be a hopeful sign of things to come.