5/23/02Dr C Davis, SOTA 2002, June 10- 14, 2002 Community TB Care Making DOTS More Accessible.

5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002

Community TB Care

Making DOTS More Accessible


Why Community TB Care Initiative Was Needed Sub-Saharan Africa has some of the highest

TB case rates in the world, Countries with high prevalence for HIV, have

experienced huge increases in notified TB cases,

Traditional TB treatment policies- focused on hospital Rx during intensive phase- Health workers deliver TB treatment


Why Community TB Care Needed

- Congestion in hospital wards and medical departments

- Overstretched resources (I.e. human, material, financial)

- Patient dissatisfaction with long separation from family


Dynamics of TB and HIV in Kenya

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PILOTING THE COMMUNITY TB CARE INITIATIVE

WHO in collaboration with partners (CDC, USAID, IUATLD, KNCV, UNAIDS) implemented some operations research

Objective was to evaluate the effectiveness, acceptability, affordability, and cost-effectiveness of community-based TB care

Eight district based projects developed in six countries (Botswana, Kenya, Malawi, South Africa, Uganda and Zambia). Study from 1998-2000

5/23/02

KEY FEATURES OF THE COMMUNITY TB CARE PILOT PROJECTS

Country Project Site Setting Study design Comm. org.

Botswana Francistown Urban Hist case control study

HIV/AIDS HBC group

Kenya Machakos Rural Hist. case control study

PHC volunteer CBDs

Malawi Lilongwe Urban Hist. case control study

Guardians and CHWs

South Africa Guguletu, Cape Town

Urban Hist. case control study

Tuberculosis NGO

Hlabisa,

Kwazulu

Rural Prospect. controlled

Traditional healers

Uganda Kiboga

Kawempe

Rural

Urban

Hist case control study

Prosp. contr

Parish Dev. Committee

HIV NGO

Zambia Ndola Urban Prospective controlled

Church NGO AIDS pgm


EVIDENCE FROM THE PILOT SITES

GUGULETU, SOUTH AFRICA Designed to evaluate program performance and cost-

effectiveness of various supervision options (clinic, community and other) for TB treatment.

Major findings:

-TB treatment outcomes were better for community supervised TB treatment,

- Community supervision of treatment is more cost effective than wholly clinic based supervision

TREATMENT OUTCOMES FOR GUGULETU, SOUTH AFRICA SITETreatment outcomes for new smear positive TB cases

Outcome Clinic DOT Community Other* (n=338) (n=331) (n=54)

Cured 49% 70%Completed 9% 11% 68%Died 2% 1% 9%Defaulted 23% 14% 5%Transferred 17% 5% 17%Failure 0 < 1%*=workplace, home/self, school, hospital

Patients treated under community DOT were significantly more likely to have treatment success than patients treated in the clinic (RR 1.4, 95% CI 1.2-1.5, P<0.001)

Treatment outcomes for retreatment smear positive TB casesOutcome Clinic DOT Community Other

(n=215) (n=29) (n=8)Cured 41% 63% 33%Completed 12% 10% 15%Died 8% 3% 19%Defaulted 29% 19% 22%Transferred 9% 3% 11%Failure 0 < 1% 0


Guguletu, South AfricaG u g u l e t u s i t e : C o s t - e f f e c t i v e n e s s :

c l i n i c , c o m m u n i t y , w o r k p l a c e

C o s t p e r p a t i e n t c u r e d

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1 7 5 7

4 0 3

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• F o r n e w s m + p a t i e n t s , c o m m u n i t y - b a s e d c a r e i s 5 5 % m o r e c o s t -e f f e c t i v e t h a n c l i n i c - b a s e d c a r e

• F o r r e t r e a t m e n t p a t i e n t s , c o m m u n i t y - b a s e d c a r e i s 4 3 % m o r e c o s t -e f f e c t i v e t h a n c l i n i c - b a s e d c a r e


EVIDENCE FROM THE PILOT SITES

KIBOGA DISTRICT, UGANDA: Study designed to compare the cost-effectiveness of community

TB care to conventional hospital based care Major findings: - Patients in the intervention group twice as likely to be treated

successfully than those in the control group. - There were substantial reductions in cost and over 50%

improvement in cost-effectiveness in the intervention group. - The approach was acceptable to patients, health care workers

and the community. Major conclusion: Because of the success of this project, CB-

DOTS has been adopted as a national policy since January 2000


KIBOGA SITE Before CBDOT option (%) After CBDOT option (%)

Treatment outcomes 1997 1998-9*

Cured 76 (47.2) 166 (63.4)

Completed treatment 19 (11.8) 28 (10.7)

Failure 1 (0.6) 0

Died 25 (15.5) 37 (14.1)

Interrupted treatment 31 (19.3) 4 (1.5)

Transferred 9 (5.6) 27 (10.3)

Total 161 262

Treatment success 95 (59) 194 (74)

*

Cost-effectiveness, KIBOGA

Cost per patient treated

Substantial reduction in cost (46% for health system, 50% for patient)

Main reason for reduction = reduced length of stay in hospital

Major new costs = central level supervision, training for CB-DOTS implementation (US$17.7 per patient each), SCHWssupervision (US$9.3)

Volunteer costs negligible (<US$1 per patient)

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OTS

1998

US

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Health system Patient Volunteer


Lessons Learned From Pilot Sites

Community-based DOTS is feasible, acceptable, and cost-effective

Successful CTBC requires close collaboration with NTP and the community

Should only be implemented where there is a functioning NTP with the 5 elements of DOTS strategy in place

Managerial expertise is essential; ensuring the decentralization of logistics for TB control (e.g. drug supply, reporting outcomes etc)


Lessons Learned From Pilot Sites

Sustainability of the program must be planned from the start. A good situation analysis is required to identify appropriate community care providers.

Training and capacity building for the community structures are prerequisites for a successful CB-DOTS.

While CB-DOTS is more cost-effective, new resources are required for training of care providers, setting up systems, patient follow-up and supervision.

CTBC should complement and extend NTP capacity, not replace it.

Effective CB-DOTS requires a strong reporting system, access to lab facilities, and a secure drug supply.


Approaches To Promote Community TB Care Initiative in Africa Community TB Care is one of the strategies for

DOTS expansion in the WHO/AFRO Regional TB Control Strategic Plan (2001-2005)

Guidelines for implementation of CB-DOTS are in final draft

Scaling up of pilot projects within the countries concerned ( Kenya, Malawi, Uganda)

Promotion/Dissemination of lessons learned in CTBC Initiative through sub-regional Workshops (Nairobi May 6-10, 2002)


Thank You

5/23/02Dr C Davis, SOTA 2002, June 10- 14, 2002 Community TB Care Making DOTS More Accessible.

Documents

Transcript of 5/23/02Dr C Davis, SOTA 2002, June 10- 14, 2002 Community TB Care Making DOTS More Accessible.