Introduction of outpatient care for DS-/MDR-TB patients in Tajikistan Cape Town, December 02-06, 2015

Tajikistan profile   Mountainous landlocked country in CA (94% of the territory is covered by mountains)   Borders with China, UZB, KGZ, Afghanistan   Population is (July 2014 )   Administrative division:2 provinces (Khatlon, Soghd), 1 GBAO, 1 capital region (Dushanbe) and 13 RRS   Population below poverty line % (est. 2013)

Burden of TB and MDR-TB The highest estimated number of incident TB cases in the WHO European Region (100 per 100,000 population, 2013) Tajikistan belongs to the 27 high burden MDR-TB countries in the world and among the 18 TB High Priority Countries of WHO European Region The estimated mortality was 6.9/100,000 (excluding TB/HIV cases) (2013) A total of 6260 (77/100,000) TB cases were notified, out of these were 5017 new cases (62.3/100,000) (2014) Primary resistance is 13% and secondary is 56% (DRS ) 10% of XDR-TB among MDR-TB patients that were tested for resistance to SLDs The number of MDR-TB and XDR-TB cases continues to rise /52; 2010 – 333/245; 2011 – 598/ – 780/536; 2013 – 1065/666; 2014 – 883 diagnosed/804 enrolled , the cumulative number of diagnosed XDR-TB patients was 99 In 2015, 37 pre- and XDR-TB patients were enrolled into treatment with new and re-purposed drugs Loss-to-follow-up of TB treatment is common, with a principal reason being the necessity to migration

Challenges State budget for TB control, current government’s contribution is insufficient to cover basic costs of TB, resulting in insufficient ownership of national program Health care provision at a district level is substandard, weak infrastructure, lack of qualified staff Low TB detection rate is compounded by a limited access to a culture testing, especially to SLD (36%, 2014) All these issues are further complicated by the country’s poverty, labor migration (internal and external), lost-to-follow-up 67.3% (2011), 65.9% (2012) and 55% (2013) of the DS- TB patients were hospitalized during the intensive phase Patient- centered approach and social support services exist at a very limited scale

Treatment model The key elements of the MDR-TB treatment model are as follows: After 2-3 months in hospital, patients usually continue treatment as outpatients. Some patients refuse hospitalization and start as outpatients Most patients receive treatment at PHC facilities, but a few at district/city TB centers. The decision is based on where the live Treatment is daily – both at facilities and at home

Intervention: Psycho-social support in TB CARE I pilots Patient support team established. Members were trained on interpersonal communications During the ambulatory care psycho-emotional support was implemented by the medical providers, community and religious leaders Risk assessments for treatment interruption were made at the beginning of treatment Social support (needs) were discussed regularly: local government, PHC, TB specialists, community and religious leaders Community groups decide on support Eligible for support are: poor, severe side-effects, secondary/chronic diseases, predisposed to treatment interruption or cessation Local government exempts patients from electricity bills, land-taxes, garbage removal charges, water supply payments, provided with small financial support, monthly food supplies, firewood, extra land, construction of a separate room

Results: the proportions of registered DS and MDR-TB patients in out-patient care

Results: the proportions of eligible for PSS DS and MDR-TB patients who received PSS

LESSONS LEARNED AND BEST PRACTICES Involvement and commitment of local government and communities This approach had not been tried in the country before and gave positive results as well as contributing to the sustainability of patient support system. PSS was provided on the base of the Protocol on strengthening ambulatory treatment and psycho-social support Ambulatory treatment and social support were done on the base on the local government Orders The standard criteria for the patients’ selection were used The community groups helped to select patients The coordination of social support from local government was done in close collaboration among medical workers, community activists and religious leaders.

Thank you!