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5/23/02 Dr 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
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
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
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
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
Dynamics of TB and HIV in Kenya
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ide
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HIV Nairobi
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
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
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
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
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
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
1 0 6 5
1 7 5 7
4 0 3
7 7 6
2 4 4
9 0 8
0
5 0 0
1 0 0 0
1 5 0 0
2 0 0 0
N e w s m + R e t r e a t m e n t
19
97U
S$
C li n i c
C o m m u n i t y
W o r k p la c e
• 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
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
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
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
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)
419
227
50
100
0
100
200
300
400
500
600C
onve
ntional
hosp
ital
-bas
ed c
are
Com
munit
y-bas
ed D
OTS
1998
US
$
Health system Patient Volunteer
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
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)
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
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.
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
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)
5/23/02 Dr C Davis, SOTA 2002, June 10-14, 2002
Thank You