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The global TB situation

Reduced treatment delays for drug-resistant TB/HIV co-infected patients with decentralised care and rapid Xpert MTB/Rif test in Khayelitsha, South Africa. Helen Cox , Jennifer Hughes, Sizulu Moyo , Johnny Daniels, Vivian Cox, Mark Nicol, Gilles van Cutsem and Virginia Azevedo.

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The global TB situation

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  1. Reduced treatment delays for drug-resistant TB/HIV co-infected patients with decentralised care and rapid Xpert MTB/Rif test in Khayelitsha, South Africa Helen Cox, Jennifer Hughes, SizuluMoyo, Johnny Daniels, Vivian Cox, Mark Nicol, Gilles van Cutsem and Virginia Azevedo

  2. The global TB situation Estimated incidence, 2012 Estimated number of deaths, 2012 940,000* (0.8–1.1 million) 8.6 million (8.3–9.0 million) All forms of TB 1.1 million (1.0–1.2 million) 320,000 (300,000–340,000) HIV-associated TB 170,000(100,000–240,000) Multidrug-resistant TB 450,000(300,000–600,000) * Excluding deaths attributed to HIV/TB Source: WHO Global Tuberculosis Report 2013

  3. Access to DR-TB treatment Target Projected Actual ~450,000 incident cases annually <20% of estimated cases receive treatment WHO TB Report 2013

  4. South Africa • 18% Adult HIV prevalence • 1,000/100,000/year TB incidence • 63% of TB patients are HIV infected • TB is the leading cause of death (54,000 deaths in 2011) • ~14,000 cases of rifampicin-resistant TB (DR-TB) diagnosed in 2012

  5. The DR-TB treatment gap in South Africa Source: NDOH data 2013

  6. Delays to DR-TB treatment initiation (South Africa) References: Hanrahan et al PLoS ONE 2012; Jacobson et al ClinInf Dis 2011; Bamford et al SAMJ 2010; Heller et al IJTBLD 2010; Loveday et al IJTBLD 2012

  7. Xpert MTB/Rif for TB and DR-TB diagnosis rolled out across South Africa • Xpert for all presumptive TB • To date, 3.5 million specimens have been tested GeneXpert instrument placement across South Africa, May 2014 Time to result = 1.5 hours

  8. Benefits of rapid treatment initiation Rapid mortality (<1 month) among diagnosed patients in Tugela Ferry, KZN 90% HIV infected 98% HIV infected Gandhi et al, Am J RespCrit Care Med 2010

  9. Aim • To assess the impact of Xpert for RR-TB diagnosis on treatment initiation in the context of decentralised DR-TB treatment in Khayelitsha, Cape Town

  10. Khayelitsha Population ~ 400,000 Antenatal HIV prevalence 37% (26,000 pts on ART) ~ 5,100 TB cases registered each year (75% HIV infected) DOTS treatment success ~ 80% Approximately 200 rifampicin-resistant cases/year (75% HIV-infected) 10 health facilities providing HIV/TB/DR-TB diagnosis and treatment

  11. Khayelitsha decentralised model • Hospital admission only if clinically indicated • PHC doctors initiate treatment and review monthly in local clinics • Daily DOT and nurse management in clinics • Integration with ART provision • Specialist paediatric outreach support • Local audiometry screening service • Individual counselling, home visits, support groups, social worker support • Recording and reporting at sub-district level

  12. Implementation of interventions by year

  13. Cases diagnosed and treated by year Consistently high % of patients initiate treatment

  14. Time to DR-TB treatment LPA impact Decentralisation impact

  15. HIV and time to RR-TB treatment

  16. HIV and % initiating RR-TB treatment Xpert Across 2012-13, significant difference in treatment initiation between HIV negative and HIV infected, p<0.0001

  17. Time to treatment (2011-12, Xpert) ● deaths, censored P=0.134, Not significant

  18. Conclusions • Decentralisation of DR-TB treatment reduced time to treatment from 2.5 months to <1 month • Xpert reduced time to treatment to a median of 7 days, with more than 90% of HIV infected RR-TB cases starting treatment • Rapid diagnosis is likely to reduce early mortality among HIV infected, although earlier presentation still required • With well functioning systems, new diagnostic tests can translate into reduced time to treatment

  19. Acknowledgments • City of Cape Town Health Department • Western Cape Province • National Health Laboratory Service • Staff in Khayelitsha clinics • Médecins sans Frontières staff • DR-TB patients in Khayelitsha

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