Khayelitsha was the first site prepared to administer anti-retrovirals to pregnant HIV-positive mothers in the nineties, implemented a wide-scale HIV treatment programme for people living with HIV in resource constrained settings shortly after before moving on to showing what a difference it made when HIV and TB were treated in a one-stop shop.

Medecins Sans Frontieres and its partners the City of Cape Town and the Western Cape government have for the past three years been running a pilot project to provide treatment to DR-TB patients at primary care level.

Results are showing how a patient-centred, decentralised model of care can increase the detection of people with DR-TB and to improve their treatment outcomes ‘€“ in turn reducing DR-TB transmission in the community.

The programme has led to the number of cases diagnosed in Khayelitsha increasing from 118 in 2006 to 231 in 2009. More than 80% of patients diagnosed in 2009 and 2010 were started on treatment with the average time to treatment initiation decreasing from 71 days in 2007 to 33 days in 2010.

The treatment regimen in Khayelitsha was also strengthened by the inclusion of moxifloxacin and terizidone for all patients.

In 2010, 72% of patients were able to start treatment at their local clinic, 15% at the community-based sub-acute facility in Khayelitsha and only 13% were admitted to the centralised DR-TB hospital.

Among patients diagnosed with DR-TB in 2008, 62% were alive at 18 months after diagnosis. Given that 76% of all DR-TB patients are HIV-infected, this represented a significant improvement compared to reports from elsewhere in the country and the world.

The Khayelitsha model is based on the understanding that the majority of DR-TB is transmitted by patients who are not on treatment. Consequently, the major objectives of the project was to increase DR-TB case detection, decrease the time taken to diagnose and start treatment and improve treatment outcomes and infection control.

A range of additional supporting elements were added to the existing TB control programme, integrating the diagnosis, care and treatment of DR-TB patients into the primary health care package.

Additional elements included staff training and clinical support, DR-TB counseling and a social assistance programme, TB infection control, a local inpatient service and specialist outreach services for among others children.

Dr Gilles van Cutsem, MSF’€™s medical co-ordinator in South Africa and Lesotho, said increased access to newer, more rapid diagnostic tools would enable detection to improve dramatically.

He said it was estimated that currently only half of DR-TB cases in Khayelitsha are diagnosed. Although this is dramatic success when compared to the barely 3% of people who have access to appropriate treatment globally, Van Cutsem said it would have to be increased substantially if there was any hope of controlling the DR-TB epidemic.

Van Cutsem also said that the decentralisation of treatment would require the commitment of resources to the primary care centre, away from the expensive hospital-based programmes.