Urgent action needed to tackle drug-resistant TB
To fight this disease, patients will need support, reports MSF
THE ARDUOUS journey towards being cured of drug-resistant tuberculosis (DR-TB) requires tremendous personal strength. The patient who chooses to embark on this road can expect nearly two years of treatment, which includes six months of daily injections and a regimen of up to 20 tablets a day to swallow.
The available drugs may not cure them, and can also lead to side-effects such as hearing loss. While the treatment for DR-TB is awful, it is the only hope for cure; yet it remains difficult to access in many parts of South Africa. Medication for regular TB or ARVs for HIV is now available at most public health clinics, but many people diagnosed with DR-TB are forced to travel to hospitals far away from home and the support structures they so desperately need to help them stay the course to being cured.
For World TB Day, tomorrow, Médecins Sans Frontières (MSF) has released the outcome of the decentralised DR-TB programme we piloted in Khayelitsha in 2007 in partnership with the health departments of the City of Cape Town and the Western Cape. Our report reveals that access to DR-TB treatment is vastly improved by diagnosis, treatment initiation and management provided at clinics by primary health-care clinicians. Last year, after complete handover of services by MSF to its partners, more than 90 percent of the 190 patients diagnosed with DR-TB were started on treatment. This high rate of access sits in stark contrast to figures reported elsewhere in the country.
In 2013, fewer than half of all people diagnosed with DR-TB in South Africa were started on treatment, resulting in preventable deaths and the unnecessary onward transmission of the disease within our communities.
Our report also shows that comprehensive decentralisation not only improves access, but also costs less. We worked closely with UCT’s Health Economics Unit to show that a fully hospitalised model of care was 42 percent more expensive than a fully decentralised model, one in which most patients are started on their treatment at their local clinic and managed there for the duration of their journey towards cure. Only those too sick or weak to attend their clinic every day are admitted to hospital. Longer hospitalisation significantly drives up treatment costs.
In many cases this is not only unnecessary, but it also deprives patients of the daily support provided by the same clinic team, as well as family and friends. The prospect of hospitalisation also works as a deterrent for people to seek treatment, driving the epidemic underground and fuelling ongoing transmission. Treatment, on the other hand, rapidly reduces infectiousness.
It is not enough to increase access. Similar to other parts of South Africa, in Khayelitsha only around 50 percent of DR-TB patients successfully complete their treatment. On the up side, with double the number of patients starting treatment, this means that double the number are successfully completing treatment. On the down side, it is obvious to us that decentralisation cannot counter the effects of lengthy treatment with poorly efficacious and intolerable drugs. Our report therefore also reports on the outcomes of DR-TB patients whom we have provided with new TB drugs such as bedaquiline, and repurposed drugs such as linezolid and clofazimine.
While the national Department of Health has indicated support for trialling access to such drugs, dedicated action is needed to make them available throughout the public health sector.
We have found that unless there are more bearable drugs that can be counted on to cure DR-TB, patients will need support in every possible way. MSF has previously reported on the importance of prioritising social worker assistance for DR-TB patients, especially to assist with accessing government disability grants. While the treatment itself may be free at public hospitals, losing their job as a consequence of DR-TB diagnosis often places a huge economic burden on the patient, as well as their family.
Our report also describes additional patient support strategies that are showing encouraging outcomes. First, adherence counselling that gives patients a clear understanding of the treatment journey upon which they are embarking, and shows them how to plan around common barriers to adherence. Second, the use of intensified home- and clinic-based support when patients interrupt their treatment. Patients who do this are at high risk of being lost to care and require additional support until they pass over this difficult stretch in their treatment journey.
Finally, DR-TB patients are now provided with weekly or monthly supplies of their drugs after completion of the six-month injection phase. This means they no longer need to visit their local clinic every single day for the remaining 14-18 months of their treatment for their nurse to observe them taking their medication. It enables our patients to begin contributing once again to work, family and community life. But the cornerstone of all these strategies are our lay counsellors, many of them former DR-TB patients themselves, who provide constant support to patients.
After all, it seems wasteful to invest in expensive DR-TB drugs without funding DR-TBtrained lay counsellors who are so critical to the successful completion of treatment. Indeed, this is a minor additional cost when weighed against the cost to the health system of every new infection acquired from someone who never started treatment or was lost along the way.
The government supports decentralisation of DR-TB treatment to primary health care level. In 2011 it released a DR-TB decentralisation policy guideline (updated in 2013), which took a number of progressive steps towards comprehensive decentralisation but stopped short of allowing treatment initiation at clinics by primary care clinicians. Encouragingly, in his Budget speech last July, Health Minister Aaron Motsoaledi announced the government’s intention to embark on massive decentralisation from 100 to 2 500 sites, by scaling up nurse-initiated and managed DR-TB treatment at municipal ward level.
World TB Day 2015 is a day for reflection on past successes and failures in the management of DR-TB in South Africa. It also marks a day for committing to move forward using the best evidence we have available, and to rapidly implement programmatic, clinical and patient support strategies that improve access to treatment for all people fighting to survive DR-TB. And while strong and decisively stated commitments are important, timely delivery is what really counts.
To access MSF’s DR-TB report, see www.msfaccess.org/common-tags/world-tb-day.
A DAY TO REFLECT ON PAST SUCCESSES AND FAILURES … AND TO COMMIT TO IMPLEMENTING THE VALUABLE KNOWLEDGE WE HAVE GAINED