Abstract

1. Abstract Problem Statement: Armenia received anti-TB drugs from the Global Drug Facility to treat patients in the civil sector in January 2003, whereas the supply of anti-TB drugs for prisons is ensured by the International Committee of the Red Cross (ICRC) as from 2002, allowing anti-TB drugs for all patients. However, a high default rate in the civil sector results in a high transmission of TB infection, and therefore increases treatment costs for society. Objectives: To evaluate the efficacy of active follow-up of released prisoners under anti-TB treatment to the civil sector and its impact on the general population and related treatment costs. Design: Cross-sectional study. Setting and Population: One central penitentiary hospital in Yerevan, Armenia, using TB transfer forms and patient records analysed from January 2003 until November 2003. Intervention: The study of TB cases released from prisons covered 2 periods: from January to July 2003, no active follow-up of patients was done. From July till November 2003, patients were assisted by a doctor of the Ministry of Justice to ensure registration at TB facilities and completion of treatment. Outcome Measures: TB transfer forms and patients’ treatment cards were systematically reviewed during the period of intervention, giving % of defaulters, % of drug intakes, and completion rates. Results: In the group of patients without active follow-up, only 22% continued treatment, whereas in the group actively followed-up, 62.5% completed treatment. This means that in the group without follow-up, 78% of the patients will infect an average of 15 persons in the civil sector, resulting in about 117 TB cases. In the group with active follow-up, only 56 TB cases will be produced. For society, this represents an increased cost of USD 9360 per 100 patients compared to a cost of USD 4480 per 100 patients if active follow-up is in place together with availability of drugs in the civil sectors and prisons. Conclusions: Provision of anti-TB drugs in Armenia in the civil sector and in prisons combined with active tracking of released prisoners under treatment doubled reductions in anti-TB treatment costs. Therefore, we recommend continuing active follow-up of released prisoners under treatment since it improves drug use and treatment completion.

2. Background and setting • In Armenia, TB cases detected in the prison system constitute a disproportionately large fraction of disease burden. The prison TB prevalence is estimated to be 50 times that of the general population. • As from 2002, the ICRC is supporting the Ministry of Justice to detect promptly TB cases and treat them in the Central Penitentiary Hospital and the pre-trial detention centre through DOTS.

3. Introduction • Anti-TB drugs are supplied from 2 sources: the GDF for civilian and the ICRC for prisons. • Prisoners released while under treatment are entitled to complete a free course of DOTS. However, barriers to treatment access in TB facilities result in a high defaulter rate for patients including ex-prisoners.

4. Objectives • The MOJ supported by the ICRC follows each patient released from prisons to the TB facilities and help in basic medical/administrative steps. • To evaluate the efficacy of active follow-up of released prisoners under anti-TB treatment to the civil sector and its impact on the general population and related treatment costs.

5. Method 1 • Active follow up consists on accompanying the released prisoners while under DOTS to civilian TB facilities. This is ensured by a physician of the MOJ. • Completion rates during six months without active follow up were compared to five months with active follow up.

6. Method 2: future perspectives • An individualized automatized database is under preparation for the civilian sector that will record information of TB registers (TB03, TB10, TB12). • Such DB already exists in prisons. • In the future, the two DB will be linked to ensure information flow between prisons and the civilian sector.

7. Results 1 • Completion of treatment is 22% without active follow-up compared to 62.5% with active follow-up. • 117 additional TB cases are produced if no active follow-up compared to 56 if active follow-up.

8. Results 2 • For the society, this represents an increased cost of USD 9360 per 100 patients compared to USD 4480 per 100 patients if active follow-up is carried out together with availability of anti-TB drugs in both sectors (civil & prisons) as is as from January 2003.

9. Discussion • Informal payments are a major barrier to TB treatment access and their reduction by medical services is of utmost importance. • In the future, provision of anti-TB drugs to both sectors from one source (GDF in the civil sector) may strengthen links in between these sectors.

10. Summary • Provision of anti-TB drugs in Armenia in the civil sector through the GDF and in prisons through the ICRC combined with active tracking of released prisoners while under DOTS doubled reduction in anti-TB treatment costs.

11. Conclusion & recommendations 1 • Active follow-up of released prisoners under DOTS should continue. • Barriers to TB treatment access could be diminished through reduction of informal payments by medical services. This may be done through fourfold measures.

12. Conclusion & recommendations 2 • Increase salaries of medical professionals. • Link salaries to performance. • Transparent accounting and reporting of financial activities through clear governance of TB facilities. • Publicize patients rights in facilities and through large media coverage.