South Africa: Decentralizing care and treatment for drug-resistant TB
South Africa’s move to decentralize the treatment of drug-resistant tuberculosis (TB) has given rise to a crop of nurses equipped not only to initiate patients on HIV treatment, but also to prescribe for and monitor drug-resistant TB (DR-TB) patients. However, experts and government officials say the need for specialist physicians and hospitals will continue, based on research presented at the South African TB conference in the port city of Durban.
Before 2011, national guidelines mandated that all DR-TB
patients be initiated on treatment only after they had been
admitted to the country's handful of specialized TB hospitals.
Almost 7,400 cases of multi-drug resistant (MDR-TB) were
diagnosed in 2010, and new cases far outstripped the bed
capacity in these facilities, according to Dr Norbert Ndjeka,
director of TB, drug-resistant TB and HIV at the South African
National Department of Health.
"We will never have enough beds in our lifetime to admit all the
MDR-TB, cases and we can't keep building more hospitals," Ndjeka
told IRIN/PlusNews. "The first success has been getting the
right policies in place. The next success will be when we
declare that there are no more waiting lists. As much as we've
made the effort, we cannot say that everyone with MDR-TB gets
treatment."
South Africa has the world's third highest TB incidence and the
fifth highest number of DR-TB patients
on treatment globally, according to Ndjeka.
The new guidelines for managing drug-resistant TB, released in
August 2011, took almost two years to formulate and echo the
most recent
National Strategic Plan for HIV, TB and STIs (sexually
transmitted infections) in calling for the decentralization of
DR-TB treatment.
Government has now set a target of implementing nurse-initiated
MDR-TB treatment in all primary healthcare facilities in the
next five years. So far the rollout in South Africa's nine
provinces has been slow and uneven, but many now have at least
one decentralized MDR-TB treatment site, Ndjeka said.
From pilots to policy
Bruce Margot, the manager of the TB control programme in
the Department of Health in KwaZulu-Natal Province, has called
the national government's five-year goal
“ambitious”.
The provinces of KwaZulu-Natal and Western Cape have been
implementing decentralized or community-based
MDR-TB treatment for several years, and positive results from
both provinces provided policymakers with the evidence to
counter initial resistance to decentralized MDR-TB care.
In Khayelitsha
township, outside Cape Town, the international humanitarian
organization, Médecins Sans Frontières (MSF),
began a pilot project which found that initiating MDR-TB
patients at clinics led to an almost 70 percent increase in the
number of patients started on treatment between 2007 and 2010,
according to research presented by MSF's Jennifer Hughes. The
decentralized model allowed patients to access MDR-TB treatment
almost 30 days earlier than in the hospital-based system.
Preliminary research from KwaZulu-Natal, presented by the
Medical Research Council's Marion Loveday, also showed that
patients who initiated MDR-TB treatment at their rural clinics
had roughly the same treatment success and cure rates as those
started hundreds of kilometres away at the province's
specialized hospital near Durban.
Although patients who are severely ill and unable to walk are
still initiated in hospital, the City of Cape Town’s
department of health has adopted the MSF model to decentralize
MDR-TB treatment and care across its eight districts, and 85
percent of patients have been initiated at the primary
healthcare level since early 2012. All eight districts have been
allocated a MDR-TB professional nurse and counsellors to provide
support to clinics.
The decentralized approach may help solve South Africa's problem
of limited bed capacity, and task-shifting may help address its
shortage of doctors, but KwaZulu-Natal’s Margot cautioned
that implementing clinics will still need access to x-ray
facilities, dieticians and
TB laboratory services, which is problematic.
KwaZulu-Natal - the only province to have introduced
nurse-initiated treatment for MDR-TB - has set up about 100
mobile teams to administer the painful injections that are part
of MDR-TB treatment and plans to double the number of teams by
the end of the 2013 financial year, according to Margot. These
teams often work 11 hours a day, using old vehicles on bad rural
roads, and sometimes hike kilometres to deliver injections when
the roads run out.
"One of the great things about these mobile teams is that
through them you have access to patients' homes every day,"
Margot told IRIN/PlusNews. "So for those six to eight months [of
treatment] you are screening everyone in that house for TB."
In a
memorandum
delivered to the TB conference chairperson, Dr Martie Van Der
Walt, South Africa's Treatment Action Campaign, the global
charity, Oxfam, and Section27, a South African human rights
organization, called on the government to intensify
decentralized MDR-TB treatment and care as one of five
interventions the group felt were crucial for advancing the
fight against TB.
PlusNews
