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 2007-8 1.6 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 - 2007

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 2007

Treatment success

Failed Defaulted Died Transfer0

10

20

30

40

50

23.2

10.2

39.4

25.2

2.0% o

f p

ate

ints

sta

rtin

g

treatm

en

t

38% HIV infected

PGWC, unpublished 2010

Aims

1. Improve case detection of DR-TB2. Improve treatment outcomes3. Decrease DR-TB transmission4. Develop a model of care applicable to

other settings

Khayelitsha drug resistant TB pilot programme

AdvocacyPatient-centred care and treatment

in the communityOperationalResearch

MonitoringAnd

Evaluation

PatientSupport

• Counselling• Support groups• Defaulter tracing

Contacts

Identificationand

Screening

Monthly• New Patient Review

• Paediatric Clinic

• DR TB Task Team

Meeting

AudiologyService

Training

• Staff• NGOs• Comm. workers

CommunityAwarenessPrograms

LizoNobanda

Sub-acuteInpatientfacility

Optimal TreatmentRegimen

InfectionControl

HealthFacilitiesHomes

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 programme DR-TB pilot – additional inputs

Early results…

Improving case detection

2003/04 2005 2006 2007 2008 20090

50

100

150

200

250

14

57

116

158

209223

DR-TB cases diagnosed in Khayelitsha

DR-

TB C

ases

Est. only 54% estimated case detection

Increasing numbers starting DR-TB treatment

2003/04 2005 2006 2007 2008 20090

50

100

150

200

250

6

38

81

100

168

212

Num

ber o

f pati

ents

sta

rting

trea

tmen

t

83% were started on treatment at their local clinic

Reduced delay to treatment initiation

2005 2006 2007 2008 20090

10

20

30

40

50

60

70

80

72 71 71

50

40

Med

ian

days

bet

wee

n sp

utum

sa

mpl

ing

and

trea

tmen

t ini

tiatio

n

However, 10% of diagnosed

cases still die before treatment initiation

HIV co-infection

2003/04 2005 2006 2007 2008 20090

10

20

30

40

50

60

70

80

90

35

52

66

7974 74

% D

R-TB

cas

es w

ho a

re H

IV in

fect

ed

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

Improved survival

0 1 2 3 4 5 6 7 8 9 10 11 120

20

40

60

80

100

76.2

Months on DR TB treatment

Aliv

e %

Comparison with early data from Tugela Ferry 1-year mortality = 71%

Survival analysis for patients diagnosed with DR-TB in 2008

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150

% r

em

ain

ing

ali

ve

Time (days)

Untreated DR-TB survivalThe survivors…

Trea

tmen

t suc

cess

Faile

d

Defau

lted

Died

Tran

sfer

0

10

20

30

40

50

23.2

10.2

39.4

25.2

2.0

% o

f pate

ints

sta

rtin

g

treatm

ent

Reduced infectiousness with treatment

0 1 2 3 4 5 60

20

40

60

80

100

39.7

Months on treatment

Posi

tive

cultu

re %

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