E-DRUG: Pills not prison - drug resistant TB in South Africa (2)
----------------------------------
[This message leads on from the message that was posted January 17]
http://medicine.plosjournals.org/perlserv/?request=read-response&doi=10.1371
/journal.pmed.0040050#r1480
Tackling drug-resistant TB in South Africa: detention is not the priority
Eric Goemaere, Nathan Ford, Daniel Berman, Cheryl McDermid, Rachel Cohen
Médecins Sans Frontières
Published: February 12, 2007
We agree that there is 'No time for Denial or Complacency,' when it comes to
the spread of MDR and XDR TB in South Africa. Unfortunately, the attention
the recent Plos Medicine article generated in South Africa and
internationally has overwhelmingly focused on detention of patients.
Headlines such as 'South Africa urged to isolate 'killer' TB patients,' [1]
places the blame on patients and diverts attention from more urgent
priorities.
The TB epidemic in South Africa, as across sub-Saharan Africa, is largely
linked to HIV. In Khayelitsha township near Cape Town, new cases had risen
to around 2,000 per 100,000 in 2006, fuelled by the high prevalence of HIV.
From our experience in South Africa a number of challenges must be addressed
locally and nationally to curb MDR. Detention does not come high on this
list.
Effective MDR management requires improvements in general TB control, but
this alone will not remove the need to respond to MDR. The Western Cape has
the best TB outcomes in South Africa, thanks to enormous investments in TB
control, but despite this MDR and XDR TB cases are increasingly being
reported.
There is an urgent priority for infection control, taking into account the
context of limited resources at the primary care level and high HIV
prevalence. Data from mid-2006 show that 67% of TB patients in Khayelitsha
are HIV positive; in MSF¹s programme in Lesotho the figure rises to 92%.
Patient triage is one aspect, but the reality is that undiagnosed MDR and
XDR patients with HIV are sitting in overcrowded waiting rooms next to other
immunocompromised patients. Personal protection for health staff, starting
with basic training on infection control, needs to be improved. Structural
improvements to clinics need to be based on feasible, low-tech solutions
air extractors and windows will be more practical than UV lights and
negative pressure rooms.
Access points to care need to increase. The Western Cape has reported over
800 cases of MDR TB in the last two years and this is certainly an
underestimation. Greater diagnostic capacity and more rapid diagnosis is
needed, and this must be met with better access to treatment. Treating MDR
currently relies on hospitalization of patients, but current needs are far
greater than hospital capacity patients can wait up to 4 months for a
hospital bed.
The traditional model of leaving MDR TB management to
specialists has incapacitated health care staff at the primary care level
who receive little or no training on how to manage MDR TB. In other settings
in southern Africa the situation is even worse. In Lesotho there is
practically no access to reliable culture or drug-sensitivity testing. Given
the scarcity of human resources and the overwhelming number of co-infected
patients treatment needs to be delivered in as decentralized a manner as
possible.
In settings where clinics are saturated and patient numbers are rising, it
is not realistic to rely on a strategy of simply reinforcing DOTS and
incarcerating defaulters to respond to MDR TB. We need to apply the lessons
learnt from providing HIV care in resource-poor settings, including
decentralization of services to the primary care level, reinforcing
adherence through treatment literacy and a patient-centred approach, and
community-based support.
The reality, though, is that an integrated approach to HIV and TB is far away: around a third of MDR TB patients in Khayelitsha do not even know their HIV status.
Drug-resistant TB is not a new problem. What is new is the willingness to
detect and treat it. The lack of willingness to do so until recently has
left us with old drugs and diagnostics that make treating drug resistant TB
at best highly complex and resource intensive, and at worst impossible.
Programme-level improvements have to be met with a dramatic increase in
efforts to develop new drugs and diagnostics.
[1] McGregor S. South Africa urged to isolate 'killer' TB patients. Mail and
Guardian, 22 January 2007.
Nathan Ford
MSF London
nathan ford <nathan.ford@london.msf.org>