A decentralized model of care for drug-resistant tuberculosis in a high HIV prevalence setting Cheryl McDermid, Helen Cox, Simiso Sokhela, Gilles van Cutsem, Busisiwe Beko, Andiswa Vazi, Johnny Daniels, Virginia Azevedo, Eric Goemaere

Background In 2008: 390,000 – 510,000 incident MDR-TB cases worldwide Only 29,243 MDR-TB cases reported=7% of estimated <3% of cases receive appropriate treatment WHO, 2010 Global M/XDR-TB response plan million MDR-TB patients treated by 2015

DR-TB treatment outcomes Treatment success 62% among 4,959 MDR-TB patients in a systematic review Only 39 (0.8%) were HIV-infected (Johnston et al, PLoS One, 2009) No data on DR-TB outcomes for HIV positive patients

Key challenges Scaling up treatment Improving diagnosis & case-detection Models of care (hospital, community) Cost of treatment Optimal treatment regimens HIV and DR-TB integrated care Length and difficulty of current treatment

Khayelitsha Population circa 500,000 Antenatal HIV prevalence 30% > 15,000 on ART ~6,000 TB cases registered each year (case notification > 1,200/100,000/y) Estimated 400 rifampicin-resistant TB cases per year 10 health facilities providing TB diagnosis and treatment (including DR-TB)

Review of DR-TB in Khayelitsha Many areas identified needing support: – Long wait for treatment (bed capacity at TB hospital unable to meet demand) – High defaulter rate (>30%) – Limited knowledge and understanding of DR-TB by HCW at primary care level – No DR-TB register at the clinics (no reliable data on DR-TB numbers, defaulter rates and outcomes) – Inconsistent DR-TB screening, monitoring and contact tracing – Infection control non-existent

MDR-TB outcomes, Cape Town TB hospital % HIV infected PGWC, unpublished 2010

Aims 1.Improve case detection of DR-TB 2.Improve treatment outcomes 3.Decrease DR-TB transmission 4.Develop a model of care applicable to other settings

Khayelitsha drug resistant TB pilot programme Advocacy Patient-centred care and treatment in the community Operational Research Monitoring And Evaluation Patient Support Counselling Support groups Defaulter tracing Contacts Identification and Screening Monthly New Patient Review Paediatric Clinic DR TB Task Team Meeting Audiology Service Training Staff NGOs Comm. workers Community Awareness Programs Lizo Nobanda Sub-acute Inpatient facility Optimal Treatment Regimen Infection Control Health Facilities Homes Community

TB programme staff Standard recording Drug supply and management Laboratory support HIV/TB integrated services Treatment supporters Staff training - ongoing support DR-TB recording (evaluation) TB infection control DR-TB counsellors and social assistance Local inpatient service Specialised outreach services – pediatrics, audiology screening Existing TB programmeDR-TB pilot – additional inputs

Early results…

Improving case detection Est. only 54% estimated case detection

Increasing numbers starting DR-TB treatment 83% were started on treatment at their local clinic

Reduced delay to treatment initiation However, 10% of diagnosed cases still die before treatment initiation

HIV co-infection HIV infection rate among DS-TB cases in Khayelitsha is ~70%

Improved survival Comparison with early data from Tugela Ferry 1-year mortality = 71% Survival analysis for patients diagnosed with DR-TB in 2008

Untreated DR-TB survival The survivors…

Reduced infectiousness with treatment Culture conversion among 160 culture positive cases starting treatment 60% of culture +ves have converted at 2 months

Challenges Improving case detection – need a rapid test for all TB suspects Reducing mortality prior to treatment initiation Improving support for patients during treatment – reducing default Overcoming stigma and fear among health care staff and in the community Determining the minimum inputs required in order to scale up treatment provision elsewhere

Conclusion Decentralizing DR TB treatment to PHC led to: – Increase in case detection and started on treatment – Reduced delay to treatment initiation – 76% survival at one year on treatment increased % HIV/DR-TB co-infected detected – Reduced transmission of DR TB as most infection occurs before diagnosis and treatment

Acknowledgments City of Cape Town Health Department Western Cape Province National Health Laboratory Service Staff in Khayelitsha clinics People suffering from drug resistant TB in Khayelitsha