New Drugs, New Hope

Fighting Drug-Resistant Tuberculosis in Georgia

MSF doctor Gocha Salia examines an X-ray from a TB patient at Senaki Hospital in Georgia. Photo by Daro Sulakauri

The morning sky is veiled by steel-gray clouds when Eldar arrives for his appointment at the local hospital in the town of Senaki, in rural western Georgia, deep in the Caucasus. Rail-thin and smartly dressed in a twill blazer and jeans, the 29-year-old has been battling tuberculosis (TB) since 2006.

Back then, Eldar’s doctor put him on treatment for multi-drug resistant TB, a long and complicated regimen he was unable to complete. In 2016, ten years after his original diagnosis, Eldar was still sick, and still tested positive for the disease. He was referred to the Doctors Without Borders/Médecins Sans Frontières (MSF) program near Senaki, where he was enrolled in a new treatment using bedaquiline and delamanid, the first new tuberculosis drugs developed in nearly 50 years.

After almost two more years of grueling treatment using these new compounds, Eldar recently received the news that he had finally tested negative. Light rain begins to fall as he climbs the crumbling cement steps of the hospital and enters the small consultation area, where he will meet with his MSF doctor and counselor for a follow-up. It’s an appointment he hopes will be one of his last.

Once considered all but defeated in Georgia, TB re-emerged as a major threat to public health after the collapse of the Soviet Union. During the years of conflict, displacement, and privation that came afterward, outdated and poorly followed treatment practices led to increased drug resistance. Though the incidence of tuberculosis is lower here than in some other countries in the region, Georgia is grappling with a particularly high burden of drug-resistant TB. For patients with these forms of the disease, the standard antibiotic treatments simply do not work.

An inpatient walks the halls of Abastumani Hospital. Photo by Daro Sulakauri
They must swallow more than 10,000 pills over the course of their treatment and endure six to eight months of painful daily drug injections.

Drug-resistant TB (DR-TB) is much harder to cure than ordinary, or drug-sensitive, TB. Treatment options for the disease are extremely limited and involve long, complex, expensive, and toxic drug regimens. Even with the promise of new drugs, most patients fighting DR-TB face a minimum of nine months of treatment, a period that often stretches to two years. They must swallow more than 10,000 pills over the course of their treatment and endure six to eight months of painful daily drug injections.

MSF doctor Gocha Salia and a hospital nurse tend to a patient at Zugdidi TB Hospital. Photo by Daro Sulakauri

For patients like Eldar, the side effects of the treatment can be nearly as difficult to manage as the disease. The drugs can cause debilitating conditions that range from nausea and joint pain to psychosis and partial or total hearing loss. Eldar experienced some hearing loss during his treatment, and struggles to make out the greetings he receives from staff members as he enters the Senaki Hospital. He smiles just the same, his gaunt face brightening as he greets the medical team who have become so familiar over the course of his long and difficult journey.

Eldar meets with his doctor, MSF physician Gocha Salia, in the facility’s small consultation room, a simply furnished space painted an old-fashioned pale peach. He lowers his thin frame onto the examination table. His voice is soft as he explains how he’s been feeling, as if he is afraid to speak out loud about his recovery for fear of tempting fate and inviting back the disease that has dogged his life for so long.

MSF counselor Lika Jobava-Tchurgulia consults a patient at Zugdidi TB Hospital. Photo by Daro Sulakauri

Though he now tests negative for TB, Eldar still suffers from terrible chest pain. He is concerned that his illness could be returning. Dr. Salia asks some questions about the nature of this pain:

When exactly does it hurt?

What does it feel like?

Before he leaves, Eldar will also take a battery of other tests to check for side effects — adverse events, in the parlance of the MSF doctors currently studying the efficacy of the new drugs. A nurse will check his vision and hearing and test his reflexes to discern whether the drugs have left him with any nerve problems.

MSF nurse Maia Patsatsia checks a patient’s vision in Zugdidi. Photo by Daro Sulakauri

For now, Dr. Salia asks Eldar to lift his shirt and checks the young man’s breathing. All sounds well, and his temperature is normal too. “Don’t worry,” says Dr. Salia. “You’re doing much, much better.”

The doctor reviews a recent X-ray with his patient. The translucent images reveal heavy scarring inside Eldar’s lungs — damage left by years of infection — but no new signs of disease. In fact, says Dr. Salia, comparing the image to an older X-ray, despite the chest pain that he will likely experience for the rest of his life, Eldar’s condition is steadily improving.

Visibly relieved, Eldar pulls his jacket back on and prepares to go to the next room, where he will meet with his MSF counselor to discuss the ways he can continue to protect himself from TB. “Of course, my life has changed,” he says as he stands up to leave.

“Whenever you become negative, everyone looks at you differently. When you have the disease people are afraid of you — now that I’m cured people don’t have as much fear.”

Eldar is just one of many patients in Georgia who has benefited from receiving TB treatment with new drugs through a partnership between MSF and the Georgian Ministry of Labor, Health, and Social Affairs.

“Here in Georgia, MSF is helping the government to implement these new drugs,” explains Dr. Sylvie Goossens, MSF head of mission in Georgia. Soon after the drugs became available in 2014, MSF began working with the health ministry to implement them within the framework of endTB (Expand New Drug markets for TB), a comprehensive international project that aims to find shorter, less toxic, oral-only, and more effective treatments for the disease.

Through endTB and with MSF’s assistance, Georgia is adding the new drugs to treatment regimens, running an observational study on their safety and efficacy, and undertaking a clinical trial on new “user-friendly” treatments.

MSF currently provides and studies the effects of the new drugs in four tuberculosis hospitals in Georgia: Zugdidi in the west, near the border with the partially recognized state of Abkhazia; Batumi, a beach town on the Black Sea; Abastumani, on the southern slopes of the Meskheti mountains; and in Tbilisi, the nation’s capital. MSF teams also regularly visit several smaller health centers across Georgia, like the hospital in Senaki where Eldar received treatment.

By the end of 2016, some 300 TB patients across Georgia were started on the new treatments.

Though the studies are still under way, initial outcomes seem very promising. Of the patients started on the new drugs from April 2015 to December 2016, 86.8 percent tested negative for TB after six months of treatment. To assess the efficacy of the treatments, “we look for what is called culture conversion,” explains Dr. Goossens. Sputum samples from patients are cultured and tested for the presence of TB bacteria.

“If the treatment is effective, then when we reanalyze the sputum, the culture will convert from positive to negative, meaning that the bacteria is no longer active.”

Photos taken in the National Center for Tuberculosis and Lung Disease in Georgia’s capital, Tbilisi, clockwise from top right: Inpatients with drug-resistant TB take their treatment; doctors review an DR-TB patient’s chest X-ray; a nurse prepares patients’ TB treatment; delamanid, trade name Deltyba, a new antibiotic to treat TB; an ambulatory patient receives his twice-daily infusion of imipenem, another antibiotic used to treat drug-resistant TB. All photos by Daro Sulakauri

Social Support

However promising their results, the new drugs are only part of the picture when it comes to effectively treating DR-TB in Georgia. Strict adherence to the long, difficult, and complex regimens is crucial to ensure that patients defeat TB and that it stays defeated. “If patients are converting, it means they are on their way to being cured,” says Dr. Goossens.

“But it doesn’t mean they won’t convert back to positive if they stop their treatment. It’s essential that patients continue their treatment for its prescribed duration and remain negative. Then we can declare them cured.”

This is where MSF’s adherence counselors come in. Working closely with the doctors and nurses, MSF counselors provide the support patients need to stay on — or adhere — to their treatment. They connect patients with caregivers who can help support them after hospitalization, provide transportation stipends to ensure patients can reach health facilities for twice-daily appointments, and ensure they receive care for other medical conditions like hypertension, hepatitis, or chronic obstructive pulmonary disease. But beyond practical considerations, they also provide patients — many of whom come from precarious living conditions, or must endure extended hospital stays — with emotional support and encouragement.

An MSF vehicle waits in the parking lot outside the TB hospital in Zugdidi. Photo by Daro Sulakauri

At the health ministry’s TB hospital in Zugdidi, where the snow-capped Svaneti mountains loom on the horizon, MSF counselor and doctor Lika Jobava-Tchurgulia knocks gently on a door in the second-floor inpatient ward. Her bright yellow trench coat and chunky jewelry are a sunny contrast to the hospital’s drab plaster walls. She’s here to see Shota, an inpatient receiving treatment for extensively drug-resistant TB.

A thin, elderly man from a nearby village, Shota has been hospitalized here in Zugdidi for around six months. He is responding to his treatment, but Dr. Jobava-Tchurgulia is concerned about his mental health, and the limited support options available to him outside the hospital. She greets him and asks simple questions in a conversational tone about his day-to-day life, the care he receives at the hospital, and whether he has any family who could help to take care of him when he is discharged.

Shota explains that he has nephews in Zugdidi, but he hasn’t been in touch with them recently. Divorced from his wife and living alone before his hospitalization, he is most concerned about the state of his home and garden, which, he explains, have had no one to take care of them since he was admitted. Dr. Jobava-Tchurgulia listens carefully to his concerns and reassures him. She will get in touch with his nephews and visit Shota’s home to make sure things are in order.

And she offers to take photos of his garden.

MSF counselor Lika Jobava-Tchurgulia consults with a patient at Zugdidi TB Hospital. Photo by Daro Sulakauri

Back to Life

MSF team members aren’t the only ones who can provide essential support to TB patients struggling to adhere to their treatment. Sometimes knowing that someone has been in your shoes, and fought the same fight, can make all the difference. In Abastumani, a former resort town in the picturesque Meskheti mountains, MSF works in the local sanatorium, a grand but dilapidated building that now serves as the region’s TB hospital. It is here that Kale Mantkava defeated DR-TB — and where he now helps others fight it.

A wiry 55-year-old from the western city of Lanchkhuti, Mantkava was first diagnosed with TB in 1987. After a failed course of treatment, his disease became drugresistant. For years he lived without symptoms, but his cough returned and his health began to fail in 2011. He was admitted as an inpatient to the hospital in Abastumani, where he was one of the first patients to be enrolled on treatment with the new drugs. During his time as an inpatient, the hospital staff noticed Kale’s determination to adhere to his treatment, and the encouragement he provided to his peers.

“Patients always feel a stigma when they learn they have TB— I help to show them that it doesn’t have to be painful,” says Kale Mantkava, above, survivor of DR-TB and hospital consultant. Photo by Daro Sulakauri

When Mantkava completed his treatment in November 2016, the hospital team offered him a position as a consultant. Now he lives and works at the hospital, supporting other patients as they struggle with their hospitalization and treatment. Among other responsibilities, Mantkava runs a small library from his room at the hospital, lending out books and magazines to the inpatients. He also has a green thumb — his room is festooned with all manner of plants, all of which are thriving in the sun that streams through his tall window. The plants are an important part of his work with the other patients. Throughout the hospital, Mantkava’s flowers and other decorative plants grow happily in pots on shelves and windowsills, providing splashes of color and life in the crumbling old sanatorium. “Caring for them helps patients take their minds off the hardships of the treatment,” he says.

“Because of what I’ve been through, I know the real picture of what TB is,” he says. “Patients always feel a stigma when they learn they have TB — I help to show them that it doesn’t have to be painful.” When the chilly weather improves, Mantkava hopes to start a flower garden outside on the hospital grounds for the inpatients to care for together. When the garden blooms, it will be a sign of hope for the future — like the hospital, his colleagues, and the other patients he’s seen recover from TB and “come back to life.”