Drug-resistant TB demands new approaches

The increasing number of South Africans contracting drug-resistant tuberculosis (TB) demands a radically different approach than the current policy of isolating patients in specialised facilities for long periods. This was the message of several presentations at the first national TB conference, held in Durban this week.

In 2007, South Africa recorded over 7,000 cases of multidrug-resistant (MDR) TB, which is resistant to the two most powerful anti-TB drugs, and 536 cases of extremely drug-resistant (XDR) TB, which is resistant to almost all anti-TB drugs.

In the last year a number of South African newspapers have reported on patients with MDR and XDR-TB breaking out of prison-like hospitals in a desperate bid to see their families.

"Why do we need barbed wire and security guards to stop people getting out of a hospital?" asked Mark Heywood, executive director of the AIDS Law Project, during a presentation about the need to incorporate human rights into TB programming.

Pointing out that there was no legal basis for the forced hospitalisation of patients with drug-resistant TB, Heywood suggested that the protection of public health did not justify an abuse of human rights.

"We're not against hospitalisation per se, but we have a number of problems with the way it's being implemented," Heywood told IRIN/PlusNews after his presentation. "This is something we'd like to engage the Department of Health on."

But Dr Lindiwe Mvusi, manager of the health department's TB programme, said the policy of isolation would not change until two community-based pilot programmes dealing with MDR-TB in KwaZulu-Natal and Western Cape provinces had yielded results.

One of the pilot programmes, being run by the City of Cape Town in partnership with the international medical humanitarian organisation, Medecines Sans Frontieres (MSF), in Khayelitsha, a township outside Cape Town, arose partly out of necessity. The Brooklyn Chest Hospital, Cape Town's specialist TB hospital, simply did not have enough beds to accommodate all the patients with MDR-TB, said Dr Virginia Azevedo of the City's health department.

But, more importantly, she told delegates, the "one-size-fits-all, centralised approach doesn't work."

An analysis of treatment outcomes at Brooklyn Hospital between 2005 and 2006, before the service was decentralised, found that high numbers of patients did not complete treatment, and that 19 out of 131 patients had ultimately died.

''Why do we need barbed wire and security guards to stop people getting out of a hospital?''

The patients' HIV status did not appear to be linked to treatment success; in fact, patients who were already taking antiretroviral (ARV) medication were more likely to adhere to TB treatment.

In 2007 an out-patient clinic was opened at Brooklyn Hospital, and since then only MDR-TB patients in the initial, intensive phase of treatment, when daily injections need to be administered, have been hospitalised.

Other MDR-TB patients take their medication at home, after receiving extensive education and adherence counselling. An infection control practitioner, employed by MSF, visits patients' homes and assesses the need for modifications to reduce the chance of transmission, such as installing additional windows or a low-tech wind turbine.

Brooklyn Hospital is only 30km from Khayelitsha, but Azevedo noted that very few people could afford public transport to visit loved ones. A "step-down" in-patient facility was opened in Khayelitsha for patients not well enough to return home, but who want to be closer to their families.

Although it is still too soon to determine whether the programme is an improvement on previous outcomes, Azevedo said the goal was to improve MDR-TB case detection, reduce the level of patients defaulting on treatment, "demystify" drug-resistant TB through community and patient education, and come up with a model that could be replicated in other parts of the country.