Community TB Care

1
Community TB Care

• Making DOTS More Accessible

2
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

3
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

4
Dynamics of TB and HIV
in Kenya
190
30
TB
170
25
HIV national
150
HIV Nairobi
20
130
TB incidence/100,000
HIV pevalence adults ()
15
110
10
90
5
70
50
0
1975
1980
1985
1990
1995
2000
5
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

6
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
7
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

8
TREATMENT OUTCOMES FOR GUGULETU, SOUTH AFRICA
SITE Treatment outcomes for new smear positive TB
cases Outcome Clinic DOT
Community Other
(n338) (n331)
(n54) Cured 49
70 Completed 9 11
68 Died 2 1
9 Defaulted 23 14
5 Transferred 17 5
17 Failure 0 lt
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, Plt0.001)   Treatment
outcomes for retreatment smear positive TB
cases Outcome Clinic DOT Community Other (n2
15) (n29) (n8) Cured 41 63 33 Complet
ed 12 10 15 Died 8
3 19 Defaulted 29 19 22 Transferred
9 3 11 Failure 0 lt 1 0  
9
Guguletu, South Africa
10
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

11
 
12
Cost-effectiveness, KIBOGA
13
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)

14
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.

15
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)

16
Thank You