The much-anticipated rollout of the shorter regimen to treat drug-resistant tuberculosis (TB) has failed to make inroads leaving patients stranded across the country. Having started in March last year, only about 70 patients have received treatment – which is only being administered in four provinces.

The new oral regimen can treat drug-resistant TB within a period of six months, instead of the usual 18 months.

Reasons for the slow rollout

Francesca Conradie, a TB researcher from Wits University, was part of the team which conducted the research on the shorter treatment for drug-resistant TB. She pinpointed two reasons behind the slow rollout.

“Firstly, it only treats a certain group of patients – drug-resistant TB patients. Secondly, when we started the project, pretomanid, one of the three study drugs was not yet registered and it had to be approved by the South African Health Products Regulatory Authority (SAHPRA). It has since been approved, I think around July last year,” explained Conradie. 

According to a study which was conducted in South Africa, Georgia, and Moldova, which Conradie presented during last year’s IAS Conference on HIV Science, treating drug-resistant TB in a short period of time shows a high success rate. 

“We have a clinical access programme which allows us to give people who live within South African borders, access to the new medicine. This can happen before they are fully registered. We did that with bedaquiline in 2012 and 2013, and now we are doing it again, but only at four sites within four provinces; Johannesburg, Durban, Cape Town, and in the North West,” said Conradie.

Drug-resistant TB treatment

The World Health Organization (WHO), states that people with drug-resistant TB face significant economic and social costs. Only one in three access quality care and reaching the remainder of the patients remains a huge public health challenge. 

The slow rollout means that drug-resistant TB sufferers are being forced to sit through 18 months of treatment.

“Implementing the drug-resistant programme in conjunction with the Department of Health takes time, we have to do it slowly and carefully. However, we have done it much faster than any other country in the world. When change occurs within a TB programme, it takes a while,” added Conradie.

Conradie also stated that the delay might be due to the decrease in the number of people being diagnosed with TB. This could possibly stem from a reduced number of screenings during the COVID-19 lockdown. 

“The number of TB patients being diagnosed has dropped because of COVID-19. So, there has been a widening gap because people didn’t access services during the hard lockdown and they’ve been reluctant to resume services or treatment. But, our screening programme is starting to get back on track,” she said.  

Taking stock of the numbers

Conradie confirmed that between 12 000 and 15 000 people have been diagnosed with drug-resistant TB in SA.  

“In 2019 we diagnosed 12 000 cases of MDR-TB, and in 2020 and 2021, the numbers dropped to about 7 000. In normal circumstances, we diagnose about 1000 cases of extensive drug-resistant TB, but that dropped to 500 last year,” she said.

Conradie added: “I think that screening is picking up, but we aren’t as vigorous as before. I also think if you look at the overall mortality during COVID, more people died from natural causes and I think a lot of them weren’t diagnosed with TB. That’s just my opinion.” 

TB survivor adds her voice

Zihle Mbopa, a three-time TB survivor, urged the department of health to speed up the rollout. The 24-year-old said she no longer wants patients to have to go through the 18-month torture.

“Having experienced it myself, I am relieved that people will no longer have to go the long route, which often results in people defaulting on the treatment. It pains me when I see TB patients dying from the side effects which come with the 18 months,” said Mbopa.

Born and bred in Gqeberha in the Eastern Cape, Mbopa was first diagnosed with pulmonary TB in 1997 and again in 2006. In 2020 she survived the Multi-Drug Resistant TB ((MDR-TB). Pulmonary TB is caused by the bacterium mycobacterium tuberculosis, and it is contagious while MDR-TB is caused by an organism that is resistant to the two most potent TB drugs.

“I was only eight months old in 1997 and had to undergo treatment for six months. The second time, I was 9 years old and I was hospitalised for six months,” said Mbopa.

Unlike many children born in SA after 1973, Mbopa never received the BCG vaccine, which is often given to children at birth. BCG is a live vaccine given to stimulate the baby’s immune system to build antibodies to protect against TB. It isn’t, however, considered effective against pulmonary TB. 

Mbopa lost her twin brother to drug-resistant TB in 2020 while fighting the disease herself. 

“I still remember like it was yesterday. It was during the school holidays in 2019 when I went home and found out that my brother was severely ill. Doctors told us that he had TB while his health deteriorated. In January 2020, he was finally diagnosed with MDR-TB, but sadly only lived for three days,” said Mbopa.

She added: “I wasn’t feeling well myself so I decided to go for a TB test. The results came back two weeks after my brother’s death, I had tested positive. Only this time, it was a different form of TB (MDR-TB). I was so terrified after my brother died.” 

According to Statistics South Africa, tuberculosis remained the main leading cause of death in the three-year period (2016-2018). However, the proportion of deaths dropped from 6.5% in 2016 to 6.0% in 2018.

TB Alliance stated that tuberculosis is a global pandemic, killing someone approximately every 22 seconds and about 1.4 million in 2019 alone.

Conradie said South Africans can expect a nationwide rollout within a year.

“Pretomanid must be included on the essential medicines list and we have to change our guidelines which will probably happen within six months to a year,” she said.  

The National Department of Health confirmed that most patients are supposed to receive the shorter treatment regimen.

“Prior to the introduction of the shorter treatment regimen, we had a treatment loss to follow up rate of between 20 and 25% and a death rate of 20% nationally. The treatment loss to follow-up has been reduced to 15% and the death rate has equally decreased. This is good but it’s a work in progress. We need to do more.” – Health-e News