KHOPOTSO: In order to eliminate tuberculosis, the government has committed to the World Health Assembly’€™s target of detecting 70% of all infectious TB cases. The second goal is to cure 85% of detected infections, with a low defaulter rate of 5%. But the actual figures show that the country is far from achieving those goals. Dr Lindiwe Mvusi is the manager of the National TB Control Programme in the Health Department.

Dr LINDIWE MVUSI: Currently, we are standing at 54% cure rate. And you find that most of the patients, about 12% of the patients, are actually defaulting treatment. A small percentage would die. It’€™s about 1.7% who are reported as deaths.

KHOPOTSO: The remaining 33% of cases cannot be accounted for.

Dr LINDIWE MVUSI: We really don’€™t know what has happened to them. They’€™ve either moved to another area or they’€™ve just been lost to follow-up and never been evaluated at the end of the treatment period so that we know whether they completed their treatment or they were cured or whether they died.

KHOPOTSO: I asked Dr Mvusi if it was due to the inadequacy of the health system that patients cannot be accounted for.

Dr LINDIWE MVUSI: I wouldn’€™t say inadequacy of the health system, as such’€¦ I want to believe if a patient knows that ‘€œI need to take treatment for 6 months’€, wherever you go’€¦ they know that they can go into any clinic if they run out of medicines and they will be given medicines’€¦ They will never be turned away’€¦ But it is this person who does not see the need to go on with the treatment’€¦

KHOPOTSO: Professor Mary Edginton, a public health specialist at Johannesburg’€™s Wits University and manager of the TB Care Centre at Chris Hani Baragwanath Hospital, in Soweto, says patients cannot solely take the blame for treatment interruption.

Prof. MARY EDGINTON: We don’€™t always take the time we should to explain to patients so they know exactly what is going on, how long their treatment is, what’€™s going to happen to them, what the risks are, what the risks of spreading elsewhere are. And if we’€™re really going to manage the problem we need to start with a patient-centred approach: What do they need; what do they want and; how to get the information across to them.

KHOPOTSO: The Directly Observed Treatment or DOT support programme aims to help TB patients with information and to overcome their problems.

Under the DOT programme, patients take six months of TB medication under the counsel and support of a community health worker. Prof. Edginton believes the system is not as effective as it should be for one particular reason.  

Prof. MARY EDGINTON: We take DOTS supporters, we give them a little bit of training and then, expect that they will take over an important function of the health service’€¦

KHOPOTSO: Dr Mvusi admits the fact and cites that sustaining the DOT supporter programme is difficult.

Dr LINDIWE MVUSI: They are volunteers in most cases. Then, they are trained to look after TB patients. But since they’€™re not getting anything ‘€“ a stipend or whatever ‘€“ then, it’€™s not sustainable because if that person is looking for employment they will leave. They are not committed to this for the rest of their lives. They will leave once they get better employment opportunities.  

KHOPOTSO: In a move to attract more volunteers and to prevent DOT supporters from leaving the programme the national Department of Health will later in the year implement a policy announced last year, where DOT supporters will be paid a stipend of R1000 per month.

Without sufficient information and support, patients are most likely to interrupt or stop taking treatment. This, then, results in a strain of the illness called Multi-Drug Resistant Tuberculosis. This is when the disease fails to respond to the only medicines available to treat and cure TB. Unlike with primary TB, the prevalence is not very high. But this form of TB poses a massive challenge for curbing new infections in the general population.

Dr LINDIWE MVUSI: Well, it’€™s still standing at about 1.6% amongst new cases and about 6.7% amongst re-treatment cases’€¦ The success rate in terms of the cure rate still remains low at about 50%, which is expected because the drugs that we’€™re currently using, anyway, are not said to be the best that are available’€¦

KHOPOTSO: HIV is another factor adding to the burden of the TB epidemic in the country. But, Prof. Mary Edginton stresses that even with HIV Tuberculosis is curable if patients are given sufficient correct information early on. She says MDR-TB is a health service mismanagement issue.

Prof. MARY EDGINTON: It means that the health service has not educated the patient about the need to take the treatment regularly, has not been accessible to patients. So, patients may have to travel long distances to get their treatment. In rural areas this can be difficult. In urban areas it can be difficult. These are not normal, healthy people. And these are poor people’€¦ So, these are the people who find it difficult to get to the clinics to have their treatment.

KHOPOTSO: From the Department’€™s point of view, it is agreed that if patients got quality education about TB, the target of an 85% cure rate would be within reach and the rate of Multi-Drug Resistant TB would be even lower.          

Dr LINDIWE MVUSI: Our problem highlights the need for us to focus on adherence strategies in terms of communication and (to) get patients educated about the need for them to actually complete the treatment that they are taking for them to be cured at the end of the treatment period; and why they actually need to do that because it’€™s not only about getting cured. You are continuing spreading the disease in the communities; and you are preventing yourself from dying from the disease when it’€™s curable; and the other issue is that you are also preventing yourself from getting the resistant form of Tuberculosis.

KHOPOTSO: For Prof Edginton, while the DOT support programme is an excellent intervention, it needs to be strengthened.  

Prof. MARY EDGINTON: Like anything else, it needs planning, monitoring, evaluating. And we need to educate and support those DOTS supporters much more than we are.