In a pilot project in Khayelitsha
In a pilot project in Khayelitsha

Treating patients with drug-resistant tuberculosis (TB) at clinics closer to their homes instead of in hospitals, which are often further away, is 42% cheaper as well as better for patients’ quality of life, according to a new report released by Médecins Sans Frontières (MSF) ahead of World TB Day on March 24.

Each year about 15 000 cases of drug-resistant TB (DR-TB) are diagnosed in South Africa; the highest number of cases in the world behind India. It requires a minimum of 20 months of treatment, which includes six months of daily injections and up to 20 tablets a day that can lead to serious side-effects like deafness.

Traditionally, DR-TB patients are treated in hospital for at least six months because the complex condition requires expertise not usually found in primary healthcare settings like clinics. But in 2007 Médecins Sans Frontières, working with the provincial health department, began a pilot project to decentralise DR-TB services in Khayelitsha, Cape Town.

Eliminating transmission
Since the beginning of the pilot project more than 90% of patients with DR-TB are started on treatment, according to the MSF report.

“This is much higher than the rest of the country where fewer than 50% of DR-TB cases are actually initiated on treatment,” said the co-ordinator of the Khayelitsha project, Lynne Wilkinson. “The most important thing is to get people started on treatment because that is when they stop being infectious and won’t transmit DR-TB to people around them.”

Resistance can develop when antibiotics are not taken correctly or TB treatments are stopped before the end of a drug course. But, according to the report, about half of the DR-TB cases in Khayelitsha are new TB cases, which means those people were directly infected with the drug-resistant strain.

Decentralisation argument
Treating DR-TB in hospital “removes a patient from their support base like family and friends as well as trusted health workers in local clinics who the patient may have a bond with,” said Wilkinson.

Patients are less likely to seek treatment if they don’t want to be in hospital and those who have jobs lose valuable time away from work, she said. “They would rather sit in their communities remaining infectious,” she added.

Norbert Ndjeka, the head of TB for the health department, says there are only 2 500 hospital beds for people with DR-TB – 12 500 short of the estimated need.

“Not only is hospitalisation of patients who are not very sick unnecessary and expensive, but there aren’t enough beds, so they are put on waiting lists until one becomes available – again remaining infectious in their communities and driving up the epidemic,” said Wilkinson.

The health department announced a decentralisation policy in 2011 but has been slow to implement it; four years later the country has only about 70 decentralised sites with staff trained to diagnose and treat DR-TB, according to MSF.

Positive results
In his budget vote speech earlier this year, Health Minister Aaron Motsoaledi said the number of decentralised sites would be increased to 2 500.

About half of the patients in the Khayelitsha project are cured or have nearly completed treatment – a similar treatment success rate to the rest of the country. But, according to the MSF report, this is largely a result of the treatment being “toxic”, “lengthy” and “poorly efficacious”.

The report authors noted that, “even with treatment success rates remaining near 50%, a greater number of prevalent cases are being successfully treated than before 2007, with [a] potential impact on the rate of ongoing DR-TB transmission in the community”.

MSF handed the project over to the provincial health department in 2013.

“If there is a cost-saving of 42% by treating patients closer to home instead of in hospital, we can use that money to capacitate more primary health facilities to treat DR-TB patients and, in the end, we can afford to put many more patients on treatment,” said Wilkinson.

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