1. Reduced treatment delays for drug-resistant TB/HIV co-infected patients with decentralised care and rapid Xpert MTB/Rif test in Khayelitsha, South Africa
Helen Cox, Jennifer Hughes, Sizulu Moyo, Johnny Daniels, Vivian Cox, Mark Nicol, Gilles van Cutsem and Virginia Azevedo

2. The global TB situation
Estimated incidence, 2012
Estimated number of deaths, 2012
940,000*
(0.8–1.1 million)
8.6 million
(8.3–9.0 million)
450,000 (300,000–600,000)
All forms of TB
Multidrug-resistant TB
HIV-associated TB
1.1 million
(1.0–1.2 million)
320,000
(300,000–340,000)
Source: WHO Global Tuberculosis Report 2013
Despite some improvements, TB still exerts an enormous global toll and in most high HIV and TB prevalence settings, TB is the leading cause of death among people living with HIV
170,000 (100,000–240,000)
* Excluding deaths attributed to HIV/TB

3. Access to DR-TB treatment
Target
Projected
Actual
Poor progress in scaling up DR-TB treatment globally
~450,000 incident cases annually
<20% of estimated cases receive treatment
WHO TB Report 2013

4. South Africa 18% Adult HIV prevalence 1,000/100,000/year TB incidence
63% of TB patients are HIV infected
TB is the leading cause of death (54,000 deaths in 2011)
~14,000 cases of rifampicin-resistant TB (DR-TB) diagnosed in 2012

5. The DR-TB treatment gap in South Africa
Source: NDOH data 2013

6. Delays to DR-TB treatment initiation (South Africa)
Setting
Diagnostic method
Median time to DR-TB treatment initiation
Northern Cape,
Line probe assay
62 days
Western Cape,
55 days
Western Cape Hospital, 2007
Culture and DST
44 days (hospitalised patients)
KwaZulu Natal,
84 days
KwaZulu Natal,
72 days
References: Hanrahan et al PLoS ONE 2012; Jacobson et al Clin Inf Dis 2011; Bamford et al SAMJ 2010; Heller et al IJTBLD 2010; Loveday et al IJTBLD 2012

7. Xpert MTB/Rif for TB and DR-TB diagnosis rolled out across South Africa
Xpert for all presumptive TB
To date, 3.5 million specimens have been tested
GeneXpert instrument placement across South Africa, May 2014
Time to result = 1.5 hours

8. Benefits of rapid treatment initiation
Rapid mortality (<1 month) among diagnosed patients in Tugela Ferry, KZN
90% HIV infected
And of course, reduced community transmission
98% HIV infected
Gandhi et al, Am J Resp Crit Care Med 2010

9. Aim
To assess the impact of Xpert for RR-TB diagnosis on treatment initiation in the context of decentralised DR-TB treatment in Khayelitsha, Cape Town

10. Khayelitsha Population ~ 400,000
Antenatal HIV prevalence 37% (26,000 pts on ART)
~ 5,100 TB cases registered each year (75% HIV infected)
DOTS treatment success ~ 80%
Approximately 200 rifampicin-resistant cases/year (75% HIV-infected)
10 health facilities providing HIV/TB/DR-TB diagnosis and treatment

11. Khayelitsha decentralised model
Hospital admission only if clinically indicated
PHC doctors initiate treatment and review monthly in local clinics
Daily DOT and nurse management in clinics
Integration with ART provision
Specialist paediatric outreach support
Local audiometry screening service
Individual counselling, home visits, support groups, social worker support
Recording and reporting at sub-district level
The decentralised model of care is integrated into the existing TB/HIV treatment programme at primary health care level.
Patients are only admitted to hospital if clinically necessary; the majority of patients are diagnosed, initiated on treatment and reviewed regularly in their local clinics by PHC doctors.
Patients attend clinic for daily DOT by the nurses, who also monitor and manage common side effects, with referral to the doctor as necessary.
All HIV positive patients with DR-TB are routinely initiated on HAART in the same clinic by the PHC doctors.
Paediatric cases or contacts are reviewed monthly by a visiting paediatric specialist, and all DR-TB patients have access to a local hearing screening service provided by MSF.
Patients are further supported throughout their treatment with individual counselling and home visits, weekly support groups and psycho-social assistance.

12. Implementation of interventions by year
2009
2010
2011
2012
2013
DST Method
Culture (phenotypic)
Mix of Culture (phenotypic) and LPA
LPA
Xpert
RR-TB model of care
Centralized
Limited decentralization
Improved programme implementation
Full decentralization

13. Cases diagnosed and treated by year
2009
2010
2011
2012
2013
No. diagnosed
Not available
218
212
195
219
210
No. treated
158
257
182
173
191
197
% treated
83.5
85.8
88.7
87.2
93.8
Consistently high % of patients initiate treatment

14. Time to DR-TB treatment
LPA impact
Decentralisation impact

15. HIV and time to RR-TB treatment

16. HIV and % initiating RR-TB treatment
Xpert
Across , significant difference in treatment initiation
between HIV negative and HIV infected, p<0.0001

17. Time to treatment (2011-12, Xpert)
● deaths, censored
P=0.134, Not significant

18. Conclusions
Decentralisation of DR-TB treatment reduced time to treatment from 2.5 months to <1 month
Xpert reduced time to treatment to a median of 7 days, with more than 90% of HIV infected RR-TB cases starting treatment
Rapid diagnosis is likely to reduce early mortality among HIV infected, although earlier presentation still required
With well functioning systems, new diagnostic tests can translate into reduced time to treatment

19. Acknowledgments City of Cape Town Health Department
Western Cape Province
National Health Laboratory Service
Staff in Khayelitsha clinics
Médecins sans Frontières staff
DR-TB patients in Khayelitsha