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ADRESSING MDR TB IN THE CONTEXT OF HIV:  Lessons from Lesotho. Dr Hind Satti PIH Lesotho Director MDR-TB program. TB Situation in Lesotho. 12,275 TB new cases notified in 2007 Estimated prevalence of 544 per 100,000 population

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ADRESSING MDR TB IN THE CONTEXT OF HIV:  Lessons from Lesotho

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Adressing mdr tb in the context of hiv lessons from lesotho l.jpg

ADRESSING MDR TB IN THE CONTEXT OF HIV:  Lessons from Lesotho

Dr Hind Satti

PIH Lesotho

Director MDR-TB program


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TB Situation in Lesotho

  • 12,275 TB new cases notified in 2007

  • Estimated prevalence of 544 per 100,000 population

  • Estimated annual incidence for all cases is 691 per 100,000 population

  • Estimated incidence of Sputum smear positive cases is 281 per 100,000 population

  • 75% of new TB cases among age-group 15-44 years

  • Estimated all TB deaths is 107/100,000 annually

  • The HIV prevalence rate in Lesotho stands at 23.2% in 2005

  • 64% of TB cases are HIV positive (WHO 2007), 80% (NTP 2008)


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The Social Context of Drug-Resistant TB

  • Drug-resistant TB patients vulnerable population

  • Disease has socioeconomic causes and consequences

  • Addressing adherence is key to treatment success

  • Community-based models of care ideal for addressing these issues


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Socioeconomic Causes and Consequences of TB

  • Poor housing

  • Malnutrition

  • Overcrowding

  • Poverty

  • Poor infrastructure


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WHAT ARE THE BARRIERS TO CARE?

  • Diagnosis of TB and MDR-TB in patients with HIV

  • Having facilities to care for very sick patients

  • Infection control in a high HIV setting

  • Having a mechanism to deliver MDR-TB care (± HIV treatment) in urban and rural areas

  • Shortage of trained human resource

  • Extreme poverty (the social and economic devastation)

  • Migration of workers to South Africa to work in the mines


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Diagnosis: Built laboratory capacity for mycobacterial culture and drug susceptibility testing


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Drugs: quality-assured drug supply at an affordable price


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Facility to care for the very sick: refurbishment of an existing hospital to create an MDR-TB/HIV center of excellence


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Inpatient Care

  • Very sick patients

    • Bedridden

    • Severely wasted

  • Severe side effects

    • Severe hypokalemia

    • Acute renal failure due to injectable and ARTs.

  • Severe OIs

    • Cryptococcal meningitis

    • CMV retinitis


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Infection control in a high HIV setting: masks for all staff and state-of-the art ventilation in facilities

Occupational policy.


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Adherence

  • Adherence crucial in successful treatment of drug-resistant TB

  • Barriers to adherence are socioeconomic and must be addressed

  • Adverse effects also contribute to poor adherence


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Accompaniment (including Directly Observed Therapy (DOT))is the basis for successful treatment

  • Accompaniment allows programs to ensure that patient will complete an adequate course of treatment.

  • Accompaniment facilitates the management of side effects and the prevention of some of them.

  • Through the process of Accompaniment, medical worker can predict and prevent the episodes of non-adherence

  • When patients receive all their medications under observation they become non-infectious sooner, and this helps reduce transmission


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Community-Based Care

  • Twice-daily DOT

  • Injections

  • Psychosocial support

  • Screening household contacts

  • Accompaniment to clinical visits

  • Offer HTC, FP, chronic disease screening and HCG at home.


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Poverty: assistance with food, housing, fuel and transportation


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Facts about the program

  • Over 200 patients enrolled on treatment.

  • 30% were from mining companies.

  • 80% MDR-TB/HIV co-infection.

  • NO DEFULTERS.

  • All co-infected patients were started on ARVs regardless of their CD4 count.

  • Decentralized to all districts hospitals.

  • Over 2000 community health workers were trained.

  • All children on treatment are orphans: lost both parents or one of them due to MDR TB/HIV.


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Con……….

  • The program trained over 200 health workers from all districts.

  • We offer international training for other countries on MDR TB/HIV and infection control (3 groups from 3African countries were trained).


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