1. 5/23/02Dr C Davis, SOTA 2002, June 10- 14, 2002 Community TB Care Making DOTS More Accessible

2. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 Why Community TB Care Initiative Was Needed Sub-Saharan Africa has some of the highest TB case rates in the world, Countries with high prevalence for HIV, have experienced huge increases in notified TB cases, Traditional TB treatment policies - focused on hospital Rx during intensive phase - Health workers deliver TB treatment

3. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 Why Community TB Care Needed - Congestion in hospital wards and medical departments - Overstretched resources (I.e. human, material, financial) - Patient dissatisfaction with long separation from family

4. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 Dynamics of TB and HIV in Kenya 50 70 90 110 130 150 170 190 197519801985199019952000 TB incidence/100,000 0 5 10 15 20 25 30 HIV pevalence adults (%) TB HIV national HIV Nairobi

5. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 PILOTING THE COMMUNITY TB CARE INITIATIVE WHO in collaboration with partners (CDC, USAID, IUATLD, KNCV, UNAIDS) implemented some operations research Objective was to evaluate the effectiveness, acceptability, affordability, and cost-effectiveness of community-based TB care Eight district based projects developed in six countries (Botswana, Kenya, Malawi, South Africa, Uganda and Zambia). Study from 1998-2000

6. 5/23/02 KEY FEATURES OF THE COMMUNITY TB CARE PILOT PROJECTS CountryProject SiteSettingStudy designComm. org. BotswanaFrancistownUrbanHist case control study HIV/AIDS HBC group KenyaMachakosRuralHist. case control study PHC volunteer CBDs MalawiLilongweUrbanHist. case control study Guardians and CHWs South AfricaGuguletu, Cape Town UrbanHist. case control study Tuberculosis NGO Hlabisa, Kwazulu RuralProspect. controlled Traditional healers UgandaKiboga Kawempe Rural Urban Hist case control study Prosp. contr Parish Dev. Committee HIV NGO ZambiaNdolaUrbanProspective controlled Church NGO AIDS pgm

7. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 EVIDENCE FROM THE PILOT SITES GUGULETU, SOUTH AFRICA Designed to evaluate program performance and cost- effectiveness of various supervision options (clinic, community and other) for TB treatment. Major findings: -TB treatment outcomes were better for community supervised TB treatment, - Community supervision of treatment is more cost effective than wholly clinic based supervision

8. TREATMENT OUTCOMES FOR GUGULETU, SOUTH AFRICA SITE Treatment outcomes for new smear positive TB cases Outcome Clinic DOT Community Other* (n=338) (n=331) (n=54) Cured49% 70% Completed 9% 11% 68% Died 2% 1% 9% Defaulted23% 14% 5% Transferred 17% 5% 17% Failure 0 < 1% *=workplace, home/self, school, hospital Patients treated under community DOT were significantly more likely to have treatment success than patients treated in the clinic (RR 1.4, 95% CI 1.2-1.5, P<0.001) Treatment outcomes for retreatment smear positive TB cases OutcomeClinic DOTCommunityOther (n=215) (n=29)(n=8) Cured41%63%33% Completed12%10%15% Died 8% 3%19% Defaulted29%19%22% Transferred 9% 3% 11% Failure 0< 1% 0

9. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 Guguletu, South Africa

10. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 EVIDENCE FROM THE PILOT SITES KIBOGA DISTRICT, UGANDA: Study designed to compare the cost-effectiveness of community TB care to conventional hospital based care Major findings: - Patients in the intervention group twice as likely to be treated successfully than those in the control group. - There were substantial reductions in cost and over 50% improvement in cost-effectiveness in the intervention group. - The approach was acceptable to patients, health care workers and the community. Major conclusion: Because of the success of this project, CB- DOTS has been adopted as a national policy since January 2000

11. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 KIBOGA SITE Before CBDOT option (%)After CBDOT option (%) Treatment outcomes19971998-9* Cured76 (47.2)166 (63.4) Completed treatment19 (11.8) 28 (10.7) Failure 1 (0.6) 0 Died25 (15.5) 37 (14.1) Interrupted treatment31 (19.3) 4 (1.5) Transferred 9 (5.6) 27 (10.3) Total161 262 Treatment success 95 (59) 194 (74) *

12. Cost-effectiveness, KIBOGA

13. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 Lessons Learned From Pilot Sites Community-based DOTS is feasible, acceptable, and cost-effective Successful CTBC requires close collaboration with NTP and the community Should only be implemented where there is a functioning NTP with the 5 elements of DOTS strategy in place Managerial expertise is essential; ensuring the decentralization of logistics for TB control (e.g. drug supply, reporting outcomes etc)

14. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 Lessons Learned From Pilot Sites Sustainability of the program must be planned from the start. A good situation analysis is required to identify appropriate community care providers. Training and capacity building for the community structures are prerequisites for a successful CB-DOTS. While CB-DOTS is more cost-effective, new resources are required for training of care providers, setting up systems, patient follow-up and supervision. CTBC should complement and extend NTP capacity, not replace it. Effective CB-DOTS requires a strong reporting system, access to lab facilities, and a secure drug supply.

15. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 Approaches To Promote Community TB Care Initiative in Africa Community TB Care is one of the strategies for DOTS expansion in the WHO/AFRO Regional TB Control Strategic Plan (2001-2005) Guidelines for implementation of CB-DOTS are in final draft Scaling up of pilot projects within the countries concerned ( Kenya, Malawi, Uganda) Promotion/Dissemination of lessons learned in CTBC Initiative through sub-regional Workshops (Nairobi May 6-10, 2002)

16. 5/23/02 Dr C Davis, SOTA 2002, June 10- 14, 2002 Thank You