Abstract Problem Statement: Armenia received anti-TB drugs from the Global Drug Facility to treat patients in the civil sector in January 2003, whereas the supply of anti-TB drugs for prisons is ensured by the International Committee of the Red Cross (ICRC) as from 2002, allowing anti-TB drugs for all patients. However, a high default rate in the civil sector results in a high transmission of TB infection, and therefore increases treatment costs for society. Objectives: To evaluate the efficacy of active follow-up of released prisoners under anti-TB treatment to the civil sector and its impact on the general population and related treatment costs. Design: Cross-sectional study. Setting and Population: One central penitentiary hospital in Yerevan, Armenia, using TB transfer forms and patient records analysed from January 2003 until November 2003. Intervention: The study of TB cases released from prisons covered 2 periods: from January to July 2003, no active follow-up of patients was done. From July till November 2003, patients were assisted by a doctor of the Ministry of Justice to ensure registration at TB facilities and completion of treatment. Outcome Measures: TB transfer forms and patients’ treatment cards were systematically reviewed during the period of intervention, giving % of defaulters, % of drug intakes, and completion rates. Results: In the group of patients without active follow-up, only 22% continued treatment, whereas in the group actively followed-up, 62.5% completed treatment. This means that in the group without follow-up, 78% of the patients will infect an average of 15 persons in the civil sector, resulting in about 117 TB cases. In the group with active follow-up, only 56 TB cases will be produced. For society, this represents an increased cost of USD 9360 per 100 patients compared to a cost of USD 4480 per 100 patients if active follow-up is in place together with availability of drugs in the civil sectors and prisons. Conclusions: Provision of anti-TB drugs in Armenia in the civil sector and in prisons combined with active tracking of released prisoners under treatment doubled reductions in anti-TB treatment costs. Therefore, we recommend continuing active follow-up of released prisoners under treatment since it improves drug use and treatment completion.

Background and setting In Armenia, TB cases detected in the prison system constitute a disproportionately large fraction of disease burden. The prison TB prevalence is estimated to be 50 times that of the general population. As from 2002, the ICRC is supporting the Ministry of Justice to detect promptly TB cases and treat them in the Central Penitentiary Hospital and the pre-trial detention centre through DOTS.

Introduction Anti-TB drugs are supplied from 2 sources: the GDF for civilian and the ICRC for prisons. Prisoners released while under treatment are entitled to complete a free course of DOTS. However, barriers to treatment access in TB facilities result in a high defaulter rate for patients including ex-prisoners.

Objectives The MOJ supported by the ICRC follows each patient released from prisons to the TB facilities and help in basic medical/administrative steps. To evaluate the efficacy of active follow-up of released prisoners under anti-TB treatment to the civil sector and its impact on the general population and related treatment costs.

Method 1 Active follow up consists on accompanying the released prisoners while under DOTS to civilian TB facilities. This is ensured by a physician of the MOJ. Completion rates during six months without active follow up were compared to five months with active follow up.

Method 2: future perspectives An individualized automatized database is under preparation for the civilian sector that will record information of TB registers (TB03, TB10, TB12). Such DB already exists in prisons. In the future, the two DB will be linked to ensure information flow between prisons and the civilian sector.

Results 1 Completion of treatment is 22% without active follow-up compared to 62.5% with active follow-up. 117 additional TB cases are produced if no active follow-up compared to 56 if active follow-up.

Results 2 For the society, this represents an increased cost of USD 9360 per 100 patients compared to USD 4480 per 100 patients if active follow-up is carried out together with availability of anti-TB drugs in both sectors (civil & prisons) as is as from January 2003.

Discussion Informal payments are a major barrier to TB treatment access and their reduction by medical services is of utmost importance. In the future, provision of anti-TB drugs to both sectors from one source (GDF in the civil sector) may strengthen links in between these sectors.

Summary Provision of anti-TB drugs in Armenia in the civil sector through the GDF and in prisons through the ICRC combined with active tracking of released prisoners while under DOTS doubled reduction in anti-TB treatment costs.

Conclusion & recommendations 1 Active follow-up of released prisoners under DOTS should continue. Barriers to TB treatment access could be diminished through reduction of informal payments by medical services. This may be done through fourfold measures.

Conclusion & recommendations 2 Increase salaries of medical professionals. Link salaries to performance. Transparent accounting and reporting of financial activities through clear governance of TB facilities. Publicize patients rights in facilities and through large media coverage.