Lesson from the frontlines: Decentralized care and treatment for MDR-TB

Shobha Shukla, CNS (Citizen News Service)
During the 46th Union World Conference on Lung Health, that just concluded in Cape Town, I had the opportunity of visiting the close-by township of Khayelitsha, where Medecins Sans Frontieres (MSF), more commonly known as Doctors Without Borders, has, since 2007, implemented a decentralized model of multidrug-resistant TB (MDR-TB) care.
Consequently in 2011, the Department of Health of South Africa issued a national MDR-TB decentralization policy, whereby the majority of MDR-TB patients are started on treatment at their local clinic, at primary healthcare centres (PHCs) level, thus avoiding more expensive hospital stays and greatly reducing the time to start MDR-TB treatment. It is the doctors who initiate MDR-TB treatment at the PHC, but thereafter it mostly is a nurse-driven service. And they are trained to do it.

Currently there are 11 such PHCs in Khayelitsha offering integrated MDR-TB and HIV care. I went to one such clinic called Ubuntu clinic, which currently has over 8000 patients on antiretroviral treatment (ART). There are also 60 MDR-TB patients (including 7 children below 5 years of age) and 10 XDR-TB patients.

'Throw the TB out'

What struck me at first hand was the structural simplicity of the clinic with good infection control measures in place. There was a gap between the roof/ ceiling and the walls. And everywhere I looked up I could see small dome like structures called whirlybirds - when the wind turns them, they cause upward movement of air, creating negative pressure inside. The windows were large and open to 'throw the TB out.'

Dr Tutu of the clinic proudly claimed that this clinic is the biggest antiretroviral treatment (ART) site as well the biggest TB centre in Western Cape. “We have 8500 patients on ART, 60 MDR-TB patients, out of which 7 are children (0-5 years), and 10 XDR-TB patients. The first ART patient in South Africa was given treatment from this clinic”, he informed.

“The cure rate for MDR-TB is fairly high here at 72%. Everytime we have a patient cured of MDR/XDR-TB in Khayelitsha, we throw a party for all and celebrate,” said Dr Tutu.

He also explained the concept of ‘Adherence Clubs’ for PLHIV. Currently there are 110 such clubs in Khayelitsha, having 30 patients each. They meet at some community venue once every two months for rapid service delivery. At every meet the weight of each member is taken and they receive their prepacked ART pills. An annual blood investigation and clinical consultation is also done once a year. The club meetings are facilitated by a lay club facilitator/ counsellor and offer the much-needed peer support for adherence to lifelong treatment. Members discuss about individual adherence problems and are encouraged to talk to one another so that they encourage each other.

Dr Vivian Cox, Deputy Medical Field Coordinator, MSF South Africa, is all for decentralized MDR-TB care, as she finds it from experience to be “cost effective (42% less costly compared to hospitalization costs) and as medically effective as centralized care, while being much more convenient for patients, their families and their communities”.

According to Dr Cox, “In South Africa, every year only two-thirds of the actual cases of MDR-TB are diagnosed. Out of those diagnosed only two-thirds are put on treatment, and out of those put on treatment only two-thirds are cured. So out of every 100 patients infected with MDR-TB, only 17 get cured, despite the best of diagnostics and treatment available in South Africa”.

The statistics given by Dr Cox, makes the case for more countries to emulate this decentralized model. For the 18,000 patients diagnosed with MDR-TB every year in South Africa, there are only 2500 beds available in hospitals for them. So it would be better if the MDR-TB patients, who are stable, could be managed at the PHC level, leaving the hospital beds for complicated cases.

Trust the patient

Dr Cox is all for placing the patient at the centre of care for TB treatment - "We need to trust the patient. DOTS system should go. At least in continuation phase, patients should be given a month’s supply of medicines just like in HIV. They are likely to perform better."

She is also very passionate about having standardized counselling sessions for patients, that begin right after diagnosis (not waiting for non adherence to set in): "Here we talk to them in the very beginning about the barriers they might face in treatment adherence - like food insecurity, side effects of drugs, alcoholism, etc. We find solutions to their problems with their help. Patient education, and not coercion, is the best way to ensure that the patient agrees to be put on treatment and complete it. If we force them into it, there is no way they will finish it."

Along with decentralization of services, there is need to do community education and mobilization in order to reduce stigma in HIV and TB.

Dr Cox said that while stigma has reduced in Khayelitsha over the years, but there still are patients who do not want to disclose their status to their families. More than stigma it is perhaps the fear of the disease. Stigma for TB is more than for HIV.

Sometimes even hospital staff needs to be destigmatized, said Cox. "They are more afraid of MDR-TB than drug-sensitive TB. But MDR-TB is sitting amongst them and they cannot ignore it by saying we will not treat it. So we told them that the best way to protect yourself from MDR-TB is to get the patient diagnosed and put on treatment quickly. It is the unknown patients whom we do not know have MDR-TB that pose the real danger and not those with known MDR-TB. So now the staff have a better understanding."

Take evidence into account

The MSF experience has shown a number of clear benefits to MDR-TB treatment initiation at PHC level. The earlier the patients are diagnosed and started on treatment, the greater the chances of survival and the less is the chance to spread the disease. In fact, as a result of decentralization in Khayelitsha, time for treatment initiation reduced from 70 days in 2007 to 4 days in 2015. This in turn is bound to decrease transmission rates. This becomes all the more crucial given that currently 70%-80% of MDR-TB is transmitted and not acquired.
Shobha Shukla, CNS (Citizen News Service)
6 December 2015 
(Shobha Shukla is providing thematic coverage from the 46th Union World Conference on Lung Health in Cape Town, South Africa, with kind support from TB Alliance. Follow her on Twitter @Shobha1Shukla)