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Why TB financing?

Issues in TB care and financing Gesine Meyer-Rath Health Economics and Epidemiology Research Office (HE 2 RO) University of the Witwatersrand/ Boston University BEMF consolidation meeting 15 July 2011. Why TB financing?.

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Why TB financing?

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  1. Issues in TB care and financingGesine Meyer-RathHealth Economics and Epidemiology Research Office (HE2RO)University of the Witwatersrand/ Boston UniversityBEMF consolidation meeting 15 July 2011

  2. Why TB financing? • HIV care and treatment is better planned and funded than ever before in South Africa • Lots of cost and epi data is known • HIV care has ear-marked, national-level funds (Conditional grant) • HIV care has own vertical system including own distribution channels for drugs • TB diagnosis and treatment uses outdated tools and drugs and produces shoddy outcomes • Very few cost data available, not much epi data • TB care is funded at provincial level via Equitable share, like all other provincial programmes • TB care is highly localised and integrated into horizontal systems

  3. TB issues PREVENTION DIAGNOSIS Uninfected Suspect Case TB TREATMENT Cured MDR MDR-TB TREATMENT Cured XDR

  4. TB prevention PREVENTION Uninfected Suspect

  5. TB prevention • Early HIV diagnosis and ART initiation • HCT: 11.9 million people tested, but no link to TB diagnosis and treatment, not enough link to ART • ART initiation at >200 CD4 cells/µl • <350 for patients with TB since April 2010 • Initiation at <500 or irrespective of CD4 cell count? • CMX and INH prophylaxis for HIV+ves • IPT: INH prophylaxis for 6 mts irrespective of CD4 cell count after excluding active TB • INH stock-outs as a result of badly planned demand • INH/CMX combination possible but still in development

  6. TB diagnosis DIAGNOSIS Uninfected Suspect Case

  7. TB diagnosis: Issues • Coverage: Case finding • Intensified Case Finding (ICF) campaign: visited 41,000 families and screened 112,000 contacts since Feb 2011 • Sensitivity of current diagnostics (smear microscopy) • Time to result (culture, LPA, DST) • Cost of newer diagnostics (Xpert MTB/RIF, line-probe assay, drug-susceptibility testing)

  8. TB diagnosis: Current situation • Current algorithm starts with smear microscopy • Smear microscopy of sputum  technology more than 125 years old • Sensitivity of smear microscopy (ability to find TB when it is there) is approximately 70% • Sensitivity of smear microscopy in HIV+ population drops to 35-45% • Current algorithm depends on culture • Culture highly sensitive (considered ‘gold standard’) • However, takes 2-6 weeks for results • High rates of contamination, missing results

  9. Possible solution: Xpert MTB/RIF The Xpert MTB/RIF (Cepheid) test detects TB and rifampicin resistance (indication of MDR-TB) in less than 2 hours The sensitivity of Xpert MTB/RIF has been shown to be 86% in a SA demonstration study HIV status does NOT affect sensitivity of Xpert

  10. Xpert roll-out: Planned timing PHASES| PILOT | FULL PILOT|HIGH CASE| GF XPERT | CONTROL| DISTRICTS| ALL LABS FAST SCALE-UP | June 2011 | Dec 2011 | Sept 2011 | Mar 2011 | Dec 2011 | Dec 2012 SLOW SCALE-UP | June 2011 | Dec 2011 | Sept 2011 | Mar 2012 | Mar 2013 | Sept 2013 • FAST SCALE-UP scenario: Full coverage by December 2012 (Ministerial mandate) • SLOW SCALE-UP scenario: Full coverage by September 2013

  11. Patients with suspected pulmonaryMTB Current guidelines Xpert algorithm Patients without TB history All patients Patients with TB history VISIT 1 Sputum microscopy if negative GeneXpert TB culture + LPA +/- DST if negative if unsuccessful if positive Stop Sputum microscopy if negative if positive if positive if negative TB diagnosis TB diagnosis TB diagnosis VISIT 2 HIV status HIV status HIV status RIF resistant/ inconclusive (MTB+/RIF+) HIV positive/ status unknown HIV positive/ status unknown HIV positive/ status unknown HIV negative Stop HIV negative Sputum microscopy Antibiotics Antibiotics Antibiotics Antibiotics Antibiotics Chest X-ray TB culture + LPA +/- DST TB culture + LPA +/- DST Chest X-ray if resolved if resolved TB culture + LPA +/- DST Stop if negative Stop Chest X-ray if positive Stop Repeat GeneXpert if negative if negative if failed if failed TB diagnosis Stop Stop if negative VISIT 3 if un- successful Antibiotics Chest X-ray HIV status Chest X-ray TB culture + LPA TB culture + LPA +/- DST HIV positive Sputum microscopy Chest X-ray HIV negative if negative TB culture + LPA +/- DST Stop Stop if positive if positive if positive if positive if positive if positive if positive TB diagnosis TB diagnosis TB diagnosis TB diagnosis TB diagnosis TB diagnosis TB diagnosis

  12. Xpert roll-out: Cost input

  13. Xpert roll-out: Results of National TB Cost Model • Xpert leads to an increase of • 30% in TB cases diagnosed • 76% in MDR cases identified • 39% in number of patients treated • 55% in the cost of the TB diagnostic programme • 32% in the outpatient cost of the TB treatment programme if scaled-up fast • Under the Xpert scenario, • 87% of diagnosed patients are diagnosed by Xpert • 83% are diagnosed after the first visit

  14. TB treatment Uninfected Suspect Case TB TREATMENT Cured MDR

  15. Patients with diagnosed pulmonaryMTB Patients with TB history (Retreatment cases, old guidelines only) Patients without TB history (New cases) Regimen 2 (RHZES for 2 months, RHZE for 1 month, RHE for 4 months) Regimen 1 (RHZE for 2 months, RH for 4 months) Patients with INH mono-resistance Patients with RIF mono-resistance Patients with multi-drug resistant TB (MDR-TB) KNM, ETH, PZA, OFL+ TZ for 6 months + ETH, OFL+ TZ for 18 months KNM, ETH, PZA, OFL + TZ for 6 months + ETH, OFL + TZ for 18 months + Inpatient care until culture - RHZE for 2 months, RH for 4 months + OFL for 6 months

  16. TB treatment: Non-resistant TB • Community-based treatment • Good coverage, but low quality: • Low completion rate • Low cure rate • High MDR and XDR rate • 2008 NHLS data: 6,219 MDR cases and 576 XDR cases • Community-based system needs re-strengthening • PHC revitalisation • Community health-worker framework • Intensified case-finding (ICF) campaign

  17. MDR/ XDR-TB treament Uninfected Suspect Case Cured MDR MDR-TB TREATMENT Cured XDR

  18. MDR-TB treatment: Issues • Cost of drugs and monitoring of side effects • Centralised vs. decentralised care; inpatient vs. community care • Infection control • Patient autonomy • Operational challenges • Drug supply chains • Administration of daily injectibles for 6 months • Improving outcomes • Cure rates between 33% and 45% • Default rates up to 70% • Death rate at Tugela Ferry after 1 year 75% (2005-2007)

  19. MDR-TB treatment: Current situation • MDR-TB care differs vastly by province • KZN: mostly community care; GP: exclusively centralised care • Current guidelines prescribe inpatient care until culture negative (2 cultures taken 30 days apart) • currently at specialised MDR/ XDR hospitals (9 specialised, 11 decrentralised units) • 73% of known MDR/ XDR cases in 2008 were hospitalised • on average 4 months • not enough capacity (1,854 beds in Feb 2010), waiting list • at average cost per patient-day equivalent (R 1,069) 4 months cost R163,000

  20. MDR-TB treatment: Decentralised care • Decentralisation plan for MDR care approved by National Health Council • Rationale: • Low capacity and infection risk while waiting • Nosocomial transmission of MDR/XDR-TB • Patients abscond due to lack of recreational facilities, family responsibilities and lack of income • Even if ambulant, monthly trips to centralised hospitals are difficult • Decentralised care is uncoordinated and chaotic

  21. MDR-TB treatment: Decentralised care • Planned guidelines: • MDR-TB treatment at MDR units in TB hospitals (district and sub-district level) and at PHC clinics • Inpatient treatment for 8 weeks or until2 consecutive sputum smears negative • Follow-up at community level by PHC staff or mobile units and DOTS plus supporters

  22. Summary: Cost issues I • Very few data available • Cost of diagnosis modelled • Cost of treatment: • 1 study of community-based treatment (Sinanovic et al Int J TB Lung Dis 2003) • 1 study on cost of care for HIV-co-infected patients (Cleary et al Cost Effect Resource Alloc 2006) • No data on cost of MDR care • Studies on real cost of Xpert roll-out and on cost of MDR-TB inpatient care planned

  23. Summary: Cost issues II • ICF: more suspects (target: 10% growth every year) • Xpert: 30% more cases, 76% more MDR cases, 39% more patients on treatment • Higher cost • ICF: lower smear sensitivity in suspects • Xpert: more cases treated, lower transmission, less new cases (including of MDR-TB) • MDR/XDR-TB treatment decentralised with less inpatient care • Lower cost

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