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Lancet. 1999 Sep 18; 354(9183):1010.HIV/AIDS, malaria, and tuberculosis are the most formidable challenges for Southeast Asia and account for more than 40% of the global communicable disease burden, according to WHO's 52nd Regional Committee Meeting in Dhaka, India, on September 6-11, 1999. Between July 1997 and March 1999 Southeast Asia reported a 40% increase in AIDS cases, with Thailand, Myanmar, and India accounting for more than 95% of cases. "It is estimated that less than 25% of the total AIDS cases have been reported," writes WHO regional director Uton Muchtar Rafei in his biennial report. Tuberculosis still has the highest mortality in the region. The annual number of new smear positive cases has increased from 18,000 to 70,000--a 2.5% increase. The region also accounts for 80% of global leprosy cases but is expected to achieve the target prevalence rate of <1/10,000 by 2002, albeit 2 years later than planned. (full text)
Lancet. 1995 Sep 9; 346(8976):675-7.WHO projections suggest that the annual number of tuberculosis (TB) cases worldwide will reach 10.2 million by the year 2000. HIV plays a dominant role in this increase in many resource-poor countries. The internationally recommended treatment regimens for TB combine some of the six major antituberculosis drugs: isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin, and thiacetazone. WHO treatment guidelines give priority to patients according to the nature of their disease and recommend two regimens of 6-8 months duration, the longer regimen incorporating thiacetazone. Recently, WHO has favored a 6-month treatment regimen given as directly observed therapy (DOT). The disadvantages of the standard approach are the heavy workload of smear examinations, the complexity of some drug regimens, and the low rates of therapy completion. With the increasing TB case load in areas of high HIV infection prevalence, laboratories cannot do initial as well as follow-up smear examinations. In Botswana the proportion of smear-positive TB cases declined to 40% in 1992, but the overall proportion of patients who had smears performed had declined (52% in 1992). The multiple regimens in use cause confusion and nonadherence to guidelines. Nonadherence is the major risk factor for the emergence of drug resistance, and low completion rates are the most obvious signs of inadequate control programs. Alternative approaches mean ensuring high completion rates and using the most effective drugs. Regarding diagnosis, research might show that the number of smears could be reduced depending on the initial reading. There is no reason why a rifampicin-based short-course regimen could not replace the multiple regimens now in use. Rifampicin-containing regimens of 62-78 doses given intermittently have been effective and are suitable for use within a DOT program. For prevention of drug resistance, only pills combining different drugs should be used and rifampicin should be limited to the treatment of TB and leprosy.