MDR-TB treatment: Comprehensive health system response is needed

Dr Diana Wangari, CNS Special Correspondent, Kenya
Marian Loveday of the South African Medical Research Council (MRC), presented a real life interesting case study at the 46th Union World Conference on Lung Health, held in Cape Town recently, which illustrated the typical treatment journey of a multidrug-resistant TB (MDR-TB) patient in South Africa. South Africa, where a decentralized model of treatment is being adapted in most facilities, has one of the largest MDR-TB epidemics in the world found in its Kwa Zulu-Natal Province, with approximately 75% of the MDR-TB patients being co-infected with HIV.

The study sought to find out the most common health systems factors that were obstacles to optimal care. The patient was a 35 years old woman-- a single parent with three young children-- living in a rural area, 35 kilometers away from a decentralized MDR-TB hospital. The patient selected was a representative of the study sample, as her treatment was compromised by the most common health systems obstacles observed. Therefore, I invite you to take a journey with the patient and thereafter take a moment and consider why a more comprehensive health system response is needed to combat MDR-TB, and for that matter any type of TB.

The patient’s journey, which started in early 2009 when her treatment was initiated, was followed up for a period of 24 months. She was treated with standardized MDR-TB regimen according to South African guidelines. According to these guidelines, during the initial intensive phase of treatment, that usually lasts for 4–6 months, patients are put on a six-drugs regimen, including injectables, and this is followed by an additional 18 months of treatment with five oral drugs. All patients co-infected with HIV receive standard co-trimoxazole prophylaxis and are eligible to receive ART.

The guidelines also recommend initiating ART within one month of MDR-TB treatment initiation. However, when this patient started treatment in 2009, TB and HIV services were poorly integrated and she was put on ART seven months after MDR-TB treatment initiation. In the seventh month of her treatment, the patient came to the hospital for her scheduled outpatient appointment, but the hospital’s Internet based system was not working. As the laboratory website was inaccessible, the patient’s most recent sputum culture results were unavailable. Consequently, the standardized regimen was issued, despite the doctor not knowing whether the patient was responding to treatment or not. In the ninth and tenth months, the public workers’ strike affected all health facilities in KwaZulu-Natal and the patient, thinking that she would not be attended to, did not go to the facility.

During the 12th and 23rd months of her treatment, there were stock-outs of different drugs, and on both occasions only four drugs were dispensed to her for that particular month, instead of the five-drug regimen recommended by the MDR-TB treatment guidelines for the continuation phase of MDR-TB therapy. In the 15th and 21st months the patient was unable to come for treatment due to patient-related socio-economic factors-- she did not have sufficient funds to get transport to the hospital in the 21st month and in the 15th month she was unable to come to the hospital as heavy rains made the dirty road closest to her home impassable and it was too far for her to walk to the hospital. Lastly, in the 18th month, when she arrived for her appointment, her clinical notes could not be found, and the standardized regimen was issued, although, due to visual problems she had developed, the standardized regimen had been adapted for her.

In summary, for more than half (58%) of this patient’s 24-month treatment journey, she received inadequate treatment, despite adhering to her hospital visit schedules most of the time. The patient received full treatment for 10 months or 42% of the treatment time and incomplete treatment for a similar length of time. She received no treatment for four months (16% of the treatment time). But, in spite of this, due to her perseverance through the 24 months treatment period, she was cured.

Speaking to CNS (Citizen News Service), Marian Loveday said, “It is often the combination of the different obstacles which become exponential and result in the delivery of incomplete and inadequate treatment. Poorly performing National TB Control programmes escalate the problem leading to increased drug resistance.” “Although this describes only one patient’s journey, many others follow a similar path. And whilst some obstacles to sub-optimal treatment need resolution at a national or provincial level, many of the problems occur at a facility level and can be resolved at this level”, added Marian. And at this moment, I would like to ponder over these resolvable problems, as the study in South Africa is a representation of the situation happening in many other middle and low-income countries.

Dr Diana Wangari, Citizen News Service - CNS
December 16, 2015 
(Dr Diana Wangari MD, is providing thematic coverage from the 46th Union World Conference on Lung Health in Cape Town, South Africa, with kind support from Lilly MDR TB Partnership. Follow her on Twitter: @diana1wangari)