DRUG-RESISTANT TB in SOUTH AFRICA: Issues & Response _ ______ _____ _ ______ _____ ___ __ __ __ __ __ _______ ___ ________ ___ _______ _________ __ _____ ___ __ __ __ __ __ _______ ___ ________ ___ _______ _________ __ _____ Dr. Norbert Ndjeka MD, DHSM (Wits), MMed(Fam Med) (MED), Dip HIV Man (SA) Director Drug-Resistant TB, TB and HIV National Department of Health

BURDEN OF DISEASE: TB WHO estimated 1% of the population gets TB annually (490,000) ▫410,000 notified in 2009 RSA 3rd high burden country after India and China (WHO Global Report on TB Control, 2009) RSA is the 5 th high burden country globally for DR-TB with an estimated: ▫13,000 (WHO Global MDR TB Report, 2010)

MDR-TB DIAGNOSIS IN THE PUBLIC SECTOR IN SOUTH AFRICA

Factors associated with MDR-TB Defaulting drug-susceptible TB treatment High levels of transmission in the communities Socio-economic: poverty, overcrowding, malnutrition, alcohol abuse, smoking Medical: HIV, diabetes and other chronic diseases that reduce immunity Occupational: working environment which is high risk for TB transmission both in public and private sector

PERFORMANCE OF TB PROGRAMME: CURRENT Increasing incidence of TB High TB/HIV co-infection rates Poor treatment outcomes for new smear positive patients ▫Cure rate: 68% (target = 85%) ▫Defaulter rate: 8% (target less than 5) ▫Death rate: 8% High retreatment rates with even poorer treatment outcomes ▫Cure rate: 54% ▫Defaulter rate: 13% ▫Death rate: 11%

DRUG RESISTANT TB Increasing incidence of MDR-TB ▫Almost 50% of diagnosed MDR-TB cases (9000) in 2009 lost before treatment initiation, 4143 were started on treatment. ▫With 3334 patients started on MDR-TB treatment during the year 2007: Poor treatment outcomes for MDR-TB ▫Treatment success rate (2007): 42% ▫One out of 5 died on treatment, 1/5 still on treatment ▫At least 1/10 defaulted treatment

Key issues about MDR-TB treatment Treatment duration: averaging 24 months Follow up after 24 months required every 6 months for another 24 months Treatment is very costly: R 1500 per month (200 US dollars) for MDR-TB and at least 4 to 5 times more per month on a XDR-TB patient (800 to 1000 US dollars/month/XDR-TB) MDR-TB patients are infectious. When should they be allowed to go back to work?

KEY CHALLENGES Limited involvement of the private medical sector in providing MDR-TB services Cross-border issues around migrant labourers Inadequate support of MDR-TB patients in the working environment leading to job losses, treatment default Poor treatment outcomes Inadequate ACSM (advocacy, communication and social mobilization) ▫Stigma ▫Poor understanding and awareness about MDR-TB ▫Lack of community involvement

REQUIRED RESPONSE: SCALE UP ACCESS Intensified case finding in HIV positive and comprehensive management of people co-infected with HIV Early diagnosis: by increasing access to new quick & effective diagnosis such as molecular assays Early treatment through decentralization of MDR- TB care Strengthening the implementation of the DOTS Strategy Improve TB Infection Control in the workplace and residential areas

WHAT CAN BUSINESS DO TO ASSIST? Update workplace policies to include: ▫Support MDR-TB patients by special considerations for extended sick leave and providing treatment support as well as psycho- social support for employees, workplace modification ▫Conduct workplace education and awareness campaigns ▫Address stigma and discrimination

WHAT CAN BUSINESS DO TO ASSIST ? (2) Implement infection prevention and control in the workplace Provide effective occupational health services Support Government initiatives to address poverty and unemployment as part of social responsibility programmes. Support ACSM initiatives on TB and HIV

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