Cape Town — In contrast to many countries in the world where tuberculosis rates are declining, the incidence of TB in South Africa has risen by 400 percent in the past 15 years, according to the country's National Aids Council. And so in a bid to improve the TB cure rate, researchers are examining the barriers that patients encounter when trying to conform to one of the traditional pillars of TB treatment.
In line with World Health Organisation (WHO) guidelines, TB treatment in South Africa follows the Directly Observed Treatment Short Course (DOTS) protocol. This requires that patients take their daily medication, for a minimum of six months, in front of a health worker who administers and “observes” that this is done correctly.
But in the context of a huge spike in TB levels in South Africa over the past 15 years, a trend which parallels the impact of the Aids epidemic, there is growing concern that using DOTS to deliver the standard short course TB treatment is failing to serve the purpose for which it was intended.
For may patients who are either too sick to walk to their local clinic for their daily treatment, or too poor to afford transport, DOTS – as it is applied in many health districts in South Africa – is often more of a hindrance than a help in overcoming the disease.
However, the WHO clearly indicates that DOTS should not be adhered to slavishly. The “whole purpose of treatment observation would be defeated were it to limit access to care, turn patients away from treatment or add to their hardships”, states the WHO protocol.
In a presentation to the Carnegie conference on poverty alleviation at the University of Cape Town (UCT) late last year, a researcher in UCT’s Health Economics Unit, Veloshnee Govender, said that their findings showed that observation at clinics was not essential to ensure that patients took their TB treatment.
In a study of 1,200 patients in four health sub-districts in South Africa, Govender and her colleagues found that, in fact, less frequent clinic visits may contribute to “improved efficiency, higher adherence and lower patient access barriers to care”.
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The study, which investigated the barriers that patients may face in taking their treatment consistently, found that taking treatment at a clinic was the key variable that determined whether someone missed their daily dose or not.
Excluding those patients who were receiving their treatment through injections, “more than half of those who reported missing treatment doses were being observed at clinics”, said Govender.
Patients who missed treatment at clinics explained that the reason they did so was due to a number of factors, including the cost of transport, the location and distance from facilities, and the conflict between taking treatment and meeting other work and domestic responsibilities.
“I walk for more than an hour, where normally it took me half an hour to get there in the past,” said one patient surveyed in the study. “Every time I have to sit on the pavement to catch my breath and the pain in the chest… I only get three pills then I have to walk back home.”
Govender said that self-supervision, the same model used for patients living with HIV/Aids who were taking antiretroviral therapy, was a viable alternative model to consider for assisting TB patients to take their medicine.
Govender said that it was vital that health authorities considered a more “patient-focused approach to the delivery of TB treatment”. This would benefit not only those suffering from TB who needed easily accessible treatment, but also the resource-constrained health system in South Africa.
