1. A Way out of Directly Observed Therapy (DOT): Community approaches to Self-Administered Treatment for Rifampicin Resistant Tuberculosis in Khayelitsha, South Africa
Busisiwe (Buci) Beko

2. Directly observed therapy (DOT)
“Pillar of Rifampicin Resistant-TB treatment administration”
Patient travels to clinic daily
Treatment is taken under the watchful eye of a nurse
Fears exist that all DR-TB infection is acquired due to poor adherence keeps countries from moving away from DOT
Notes:

3. Could DOT be the barrier to successful treatment?
Clinic based DOT
DOT may hinder adherence
DOT is resource intensive for the clinic
Treatment Interruption
Loss from treatment
Talk about – the journey is long
Painful injections
Loads of meds
Side effects
Now ADD- going to the clinic daily- describe – waiting for files, staff going on breaks, frustrations, waiting times, time to swallow meds, difficulties
Say that you were there you were on DOTs, a young mom with a new born
It is difficult -
Could DOT be the barrier to successful treatment?

4. Self Administered Treatment (SAT)
Patients self administer treatment at home
Patient can return to work/ school/ other
Limits clinic visits
Improves quality of life
Objective:
To improve adherence by removing barriers to treatment posed by DOT

5. Eligibility Criteria for SAT
Intensive phase complete
Clinically stable and no TB symptoms present
Culture Negative
Supportive home environment
Fairly good adherence
Notes:

6. Local Community Care Worker (CCW)
SAT Description
Completion of the Intensive phase
Clinic staff flag pt.
Standardized DR-TB counseling session
Local Community Care Worker (CCW)
Home assessment
Case presented at
Multi-Disciplinary Team (MDT)
Not approved for or does not accept SAT
Referred for enhanced adherence support
Approved for and accepts SAT:
Offered a weekly or monthly supply
Adherence Planning Session
Ongoing at medicine pick-ups
CCW adherence support
Weekly home visits
Clinical Monitoring
Patient is assessed monthly during clinical visit
Monthly sputum check
Assessment
Completion of intensive phase (Session 4)
Home Assessment by Community Care Worker (CCW)
Identification of a treatment supporter
Multidisciplinary team discussion and decision
Adherence planning if approved
Weekly adherence visits and adherence monitoring
Referral for treatment interruption counseling if not approved
SAT

7. Methods
SAT was progressively implemented in five MSF-supported clinics from January 2012 – December 2014
All RR-TB patients still receiving treatment at the end of the intensive phase within the SAT clinics (SAT phase) were compared to patients in the same five clinics from January 2010 through July 2013 when DOT was the prevailing model of care (DOT phase)
Descriptive statistics and chi squared tests were conducted to assess differences in 12 month treatment outcomes.

8. Results DOT cohort SAT cohort p-value Started RR-TB treatment 160 240--
Patients in care at the end of intensive phase
122
182
Identified and eligible 17 92
Enrolled in SAT 82
12 month RR-TB treatment outcomes
n=112*
n=173**
Still on treatment
n=92 (82.1%)
n=149 (86.1%)
0.36
Loss from Treatment
n=15 (13.4%)
n=16 (9.2%)
0.27
Death
n=4 (3.6%)
n=7 (4.0%)
0.55
Treatment Failure
n=1 (0.89%)
n=1 (0.58%)
0.76
*Excluding 10 Transferred Out
**Excluding 9 Transferred Out
Explanation: Interim outcomes
No significant difference in the proportion of patients on tx at 12 months
If we look at only those who received SAT in the SAT cohort we see that 78 of the 82 with outcomes at 12 months are still in care. (97.5%)

9. Conclusions
Interim outcomes indicate that structured SAT does not lead to a reduction in the proportion of patients retained in care 12 months post treatment initiation

10. Adopt and adapt SAT models to fit your programmes
Recommendation
Lets not punish patients but work with patients and allow them a better quality of life, respecting and trusting them to comply to treatment regimens.
Adopt and adapt SAT models to fit your programmes

11. Resources Acknowledgements City and Province clinic staff
RR-TB patients and their families
MSF Khayelitsha team and government structures

13. Results Explanation: Interim outcomes
No significant difference in the proportion of patients on tx at 12 months