1 / 21

A decentralized model of care for drug-resistant tuberculosis in a high HIV prevalence setting

A decentralized model of care for drug-resistant tuberculosis in a high HIV prevalence setting. Cheryl McDermid, Helen Cox, Simiso Sokhela, Gilles van Cutsem , Busisiwe Beko, Andiswa Vazi, Johnny Daniels, Virginia Azevedo, Eric Goemaere. Background. Global M/XDR-TB response plan 2007-8

zoltin
Download Presentation

A decentralized model of care for drug-resistant tuberculosis in a high HIV prevalence setting

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. A decentralized model of care for drug-resistant tuberculosis in a high HIV prevalence setting Cheryl McDermid, Helen Cox, Simiso Sokhela, Gilles van Cutsem, Busisiwe Beko, Andiswa Vazi, Johnny Daniels, Virginia Azevedo, Eric Goemaere

  2. Background Global M/XDR-TB response plan 2007-8 1.6 million MDR-TB patients treated by 2015 In 2008: • 390,000 – 510,000 incident MDR-TB cases worldwide • Only 29,243 MDR-TB cases reported=7% of estimated • <3% of cases receive appropriate treatment WHO, 2010

  3. DR-TB treatment outcomes • Treatment success 62% among 4,959 MDR-TB patients in a systematic review • Only 39 (0.8%) were HIV-infected (Johnston et al, PLoS One, 2009) No data on DR-TB outcomes for HIV positive patients

  4. Key challenges • Scaling up treatment • Improving diagnosis&case-detection • Models of care (hospital, community) • Cost of treatment • Optimal treatment regimens • HIV and DR-TB integrated care • Length and difficulty of current treatment

  5. Khayelitsha Population circa 500,000 Antenatal HIV prevalence 30% > 15,000 on ART ~6,000 TB cases registered each year (case notification > 1,200/100,000/y) Estimated 400 rifampicin-resistant TB cases per year 10 health facilities providing TB diagnosis and treatment (including DR-TB)

  6. Review of DR-TB in Khayelitsha - 2007 Many areas identified needing support: • Long wait for treatment (bed capacity at TB hospital unable to meet demand) • High defaulter rate (>30%) • Limited knowledge and understanding of DR-TB by HCW at primary care level • No DR-TB register at the clinics (no reliable data on DR-TB numbers, defaulter rates and outcomes) • Inconsistent DR-TB screening, monitoring and contact tracing • Infection control non-existent

  7. MDR-TB outcomes, Cape Town TB hospital 2007 38% HIV infected PGWC, unpublished 2010

  8. Aims Improve case detection of DR-TB Improve treatment outcomes Decrease DR-TB transmission Develop a model of care applicable to other settings

  9. Khayelitsha drug resistant TB pilot programme Operational Research Monitoring And Evaluation Patient-centred care and treatment in the community Advocacy • Training • Staff • NGOs • Comm. • workers Infection Control Health Facilities Homes Community • Patient • Support • Counselling • Support • groups • Defaulter • tracing Contacts Identification and Screening Lizo Nobanda Sub-acute Inpatient facility Optimal Treatment Regimen • Monthly • New • Patient • Review • Paediatric • Clinic • DR TB • Task • Team • Meeting Community Awareness Programs Audiology Service

  10. Existing TB programme DR-TB pilot – additional inputs TB programme staff Staff training - ongoing support DR-TB counsellors and social assistance Standard recording DR-TB recording (evaluation) Drug supply and management TB infection control Laboratory support Local inpatient service HIV/TB integrated services Specialised outreach services – pediatrics, audiology screening Treatment supporters

  11. Early results…

  12. Improving case detection Est. only 54% estimated case detection

  13. Increasing numbers starting DR-TB treatment 83% were started on treatment at their local clinic

  14. Reduced delay to treatment initiation However, 10% of diagnosed cases still die before treatment initiation

  15. HIV co-infection HIV infection rate among DS-TB cases in Khayelitsha is ~70%

  16. Improved survival Survival analysis for patients diagnosed with DR-TB in 2008 Comparison with early data from Tugela Ferry 1-year mortality = 71%

  17. Untreated DR-TB survival The survivors…

  18. Reduced infectiousness with treatment Culture conversion among 160 culture positive cases starting treatment 60% of culture +ves have converted at 2 months

  19. Challenges • Improving case detection – need a rapid test for all TB suspects • Reducing mortality prior to treatment initiation • Improving support for patients during treatment – reducing default • Overcoming stigma and fear among health care staff and in the community • Determining the minimum inputs required in order to scale up treatment provision elsewhere

  20. Conclusion • Decentralizing DR TB treatment to PHC led to: • Increase in case detection and started on treatment • Reduced delay to treatment initiation • 76% survival at one year on treatment increased % HIV/DR-TB co-infected detected • Reduced transmission of DR TB as most infection occurs before diagnosis and treatment

  21. Acknowledgments • City of Cape Town Health Department • Western Cape Province • National Health Laboratory Service • Staff in Khayelitsha clinics • People suffering from drug resistant TB in Khayelitsha

More Related