Dr Hind Satti

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ADRESSING MDR TB IN THE CONTEXT OF HIV 
Lessons from Lesotho

• Dr Hind Satti
• PIH Lesotho
• Director MDR-TB program

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TB Situation in Lesotho

• 12,275 TB new cases notified in 2007
• Estimated prevalence of 544 per 100,000
  population
• Estimated annual incidence for all cases is 691
  per 100,000 population
• Estimated incidence of Sputum smear positive
  cases is 281 per 100,000 population
• 75 of new TB cases among age-group 15-44 years
• Estimated all TB deaths is 107/100,000 annually
• The HIV prevalence rate in Lesotho stands at
  23.2 in 2005
• 64 of TB cases are HIV positive (WHO 2007), 80
  (NTP 2008)

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The Social Context of Drug-Resistant TB

• Drug-resistant TB patients vulnerable population
• Disease has socioeconomic causes and consequences
• Addressing adherence is key to treatment success
• Community-based models of care ideal for
  addressing these issues

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Socioeconomic Causes and Consequences of TB

• Poor housing
• Malnutrition
• Overcrowding
• Poverty
• Poor infrastructure

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WHAT ARE THE BARRIERS TO CARE?

• Diagnosis of TB and MDR-TB in patients with HIV
• Having facilities to care for very sick patients
• Infection control in a high HIV setting
• Having a mechanism to deliver MDR-TB care ( HIV
  treatment) in urban and rural areas
• Shortage of trained human resource
• Extreme poverty (the social and economic
  devastation)
• Migration of workers to South Africa to work in
  the mines

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• Diagnosis Built laboratory capacity for
  mycobacterial culture and drug susceptibility
  testing

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Drugs quality-assured drug supply at an
affordable price
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• Facility to care for the very sick
  refurbishment of an existing hospital to create
  an MDR-TB/HIV center of excellence

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Inpatient Care

• Very sick patients
• Bedridden
• Severely wasted
• Severe side effects
• Severe hypokalemia
• Acute renal failure due to injectable and ARTs.
• Severe OIs
• Cryptococcal meningitis
• CMV retinitis

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• Infection control in a high HIV setting masks
  for all staff and state-of-the art ventilation in
  facilities
• Occupational policy.

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Adherence

• Adherence crucial in successful treatment of
  drug-resistant TB
• Barriers to adherence are socioeconomic and must
  be addressed
• Adverse effects also contribute to poor adherence

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Accompaniment (including Directly Observed
Therapy (DOT))is the basis for successful
treatment

• Accompaniment allows programs to ensure that
  patient will complete an adequate course of
  treatment.
• Accompaniment facilitates the management of side
  effects and the prevention of some of them.
• Through the process of Accompaniment, medical
  worker can predict and prevent the episodes of
  non-adherence
• When patients receive all their medications under
  observation they become non-infectious sooner,
  and this helps reduce transmission

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Community-Based Care

• Twice-daily DOT
• Injections
• Psychosocial support
• Screening household contacts
• Accompaniment to clinical visits
• Offer HTC, FP, chronic disease screening and HCG
  at home.

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• Poverty assistance with food, housing, fuel and
  transportation

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Facts about the program

• Over 200 patients enrolled on treatment.
• 30 were from mining companies.
• 80 MDR-TB/HIV co-infection.
• NO DEFULTERS.
• All co-infected patients were started on ARVs
  regardless of their CD4 count.
• Decentralized to all districts hospitals.
• Over 2000 community health workers were trained.
• All children on treatment are orphans lost both
  parents or one of them due to MDR TB/HIV.

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Con.

• The program trained over 200 health workers from
  all districts.
• We offer international training for other
  countries on MDR TB/HIV and infection control (3
  groups from 3African countries were trained).

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