2. Multi-drug resistant tuberculosis: Progress and challenges in South Africa Dr S. Moyo HIV/AIDS, Sexually Transmitted Infections and TB research (HAST)Programme Human Sciences Research Council Dr S. Moyo HIV/AIDS, Sexually Transmitted Infections and TB research (HAST)Programme Human Sciences Research Council 02 June 2014

3. Presentation Overview Definitions Burden of multi-drug resistant TB (MDR-TB) in South Africa Significance of MDR-TB in South Africa Successes and challenges in addressing the MDR-TB burden Recommended key actions Conclusion

4. The face of MDR-TB Photos: courtesy of Médecins San Frontières, Khayelitsha DR-TB project

5. The face of MDR-TB © Rowan Sybus www.mariellafurrer.com

6. Definitions Multi-drug resistant TB (MDR-TB) caused by mycobacteria with resistance to first-line anti TB drugs rifampicin and isoniazid Extensively drug resistant TB (XDR-TB)- MDR plus resistance to second-line drugs:-second-line injectable agent and a fluoroquinolone Pre-XDR TB MDR plus resistance to a second line injectable agent or a fluoroquinolone

7. The Burden of MDR-TB in South Africa One of the 27 high MDR-TB burden countries Second largest number of MDR-TB cases in 2012 ~10% of MDR-TB cases have XDR-TB Reports highest number of XDR-TB cases globally 1.8% of new TB cases and 6.7% of previously treated TB cases have MDR-TB ~ 4% of all TB is MDR across all provinces Most cases reported in KZN (46%), EC (19%) WC(15%) and GP(8%)- MDR-TB 2012

8. Number of laboratory diagnosed cases MDR & XDR-TB 2008-2012

9. Number of cases

10. The significance of MDR-TB Growing problem globally and threatens global TB control Now driven by community transmission More difficult to treat than drug sensitive TB More expensive to treat than drug sensitive TB

11. The significance of MDR-TB: More difficult to treat Longer duration of treatment:- at least 18 months of treatment Treatment regimens have significant side effects, and include a painful injectable agent Patient outcomes are poor < 50% treatment success rate high mortality and failure of treatment more than 12 months median survival among treatment failures

12. The significance of MDR-TB: More expensive to treat MDR TB comprising 2.2% of total TB burden but consumed 48% of total estimated National TB budget in SA in 2011. Pooran et al, PLoS One 2013 Cost of diagnostics & monitoring Cost of drugs Hospitalisation

13. Addressing MDR-TB: Progress -1 TB control is one of the key national health priorities  In the NSP specific goals for MDR-TB are Initiation of appropriate therapy with 5 days suspicion of resistance 95% pts on appropriate therapy 60% treatment success Framework for management of MDR-TB Premised on decentralised/deinstitutionalised management (hospitalisation available where necessary) Nurse initiated MDR-TB treatment

14. Addressing MDR-TB: Progress-2 Use of modern diagnostics  Molecular methods for rapid diagnosis  Hain assay- Line probe assay  XpertMTB/Rif as replacement for smear microscopy Review and evaluation of treatment regimens Monitoring of resistance patterns  National drug resistance surveys

15. Addressing MDR-TB: Progress summary National Department of health: Report on Think Tank meeting on the management of multidrug resistant Tb in South Africa- 26-28 March, 2014

16. Addressing MDR-TB:-Challenges -1 Poor case detection Patients do not present for care Patients receive inadequate/ inappropriate care Contact tracing and assessment of contacts is not always conducted Inadequate testing Drug susceptibility testing Second line drug susceptibility testing High burden of undetected disease

17. Addressing MDR-TB:-Challenges-2 Treatment initiation gap Low levels of treatment initiation

18. Addressing MDR-TB:-Challenges-3 Limited treatment regimen options Limited options for constructing effective regimens Available drugs have limited efficacy and many significant side effects Poor outcomes, High default rates Recording and reporting Poor in many areas, definitions are not always well understood Paper registers not entirely compatible with the electronic database (EDR.Web)- ?diagnosed/started on treatment reported Limited access EDR.Web

19. Addressing MDR-TB:-Challenges-4 Human resources Quantity  Nurses, doctors, counsellors, social workers, laboratory staff, audiologists/ assistants  Heavy workload with neglect of MDR TB Quality  Inadequate care to patients  Infection control measures Poor implementation of decentralisation Poor local level leadership Inadequate staff * No real buy-in on the experience of established models with possibility of scale up

20. Addressing MDR-TB:-Challenges-5 Management of patients who have failed treatment Palliative care options Balancing patients’ rights and protection of the public Community education Inadequate focus on some vulnerable groups Young children Adolescents Healthcare workers*

21. Key actions needed Increased awareness of MDR-TB to increase testing and case detection (communities and health care facilities) Strengthening of the health system for MDR-TB testing and appropriate care (accelerate rollout of nurse initiated MDR-TB treatment) Urgent review and updating of treatment regimens Increased financing Examination of successful decentralisation models for urgent scale up of access to diagnosis and care

22. Conclusion MDR-TB poses a real threat to TB control Urgent and bold steps are urgently needed to address MDR-TB Find TB, treat TB and cure TB

23. Acknowledgements Médecins Sans Frontières – Khayelitsha Project Mariella Furrer photography- www.mariellafurrer.comwww.mariellafurrer.com National Department of Health

24. Extra slides

25. Number of laboratory diagnosed cases and number started on treatment- MDR TB 2007-2012

26. Number of laboratory diagnosed cases and number started on treatment- XDR TB 2007-2012