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.