Tuberculosis (TB) remains the leading cause of death in South Africa. In 2021, TB accounted for 56 000 deaths and 304 000 people got sick with TB in the country. This is part of an alarming global trend indicating the negative impact of COVID-19 on already fragile health systems.
The South African TB Recovery Plan was developed to try and reverse the negative effects of the COVID-19 pandemic and promised to be a "target-driven, evidence-based plan aiming at finding people with undiagnosed TB, strengthening the linkage of people diagnosed with TB to treatment, retention in TB care, and TB prevention". The TB Recovery Plan is also a bridge to the new National Strategic Plan (NSP) for HIV, AIDS, STIs, and TB that is being launched this week and will be in place until 2028, and it is a response to the United Nations High-Level Meeting commitments on TB, the Sustainable Development Goals, and the End TB targets.
"Policies often stop at policy and don't have implementation plans. When they do have implementation plans, they're so complicated that nobody can work out how they work, and they don't have realistic resource allocations. It's [about] investing in the people, so they understand, and they do what they must do, giving them the tools to do what they must do, but keep it simple, and making sure that there is a resourced plan." - comment from a civil society member to TB Proof.
People affected by TB and TB advocates were hopeful that the TB Recovery Plan would use some of the learnings from the COVID-19 pandemic, yet the same sense of urgency that we saw in response to COVID-19 does not seem to be applied to TB despite its ongoing national relevance. Unlike COVID-19, it has been wreaking health havoc and death in South Africa for many years and will continue to do so, unless there is a very intentional and sustained effort to address it through evidence-based interventions.
The TB recovery plan combines several key TB policies into a nationwide call to action to use all the possible tools we have available to accelerate progress and bring the TB pandemic under control. This included expanding testing for TB, using new tools like digital X-rays (with computer-aided detection) and urine rapid tests for TB, ensuring that people diagnosed with TB are linked to care, and rolling out a more comprehensive programme nationally to treat people infected with TB ("latent TB") before they develop active TB disease.
In a series of interviews, TB Proof spoke to policymakers, civil society representatives, and health workers to find out how the implementation of the TB Recovery Plan has played out and what recommendations they had for making sure it achieves its full potential.
1. More people in South Africa need to be tested for TB
Testing is the weakest link in the TB cascade of care globally and in South Africa, where a molecular test called Xpert MTB/RIF Ultra is used as the initial test (usually done on sputum) for people being assessed for TB. During the COVID-19 pandemic, the number of tests that were done to see if people have TB dropped by 48%. Even prior to the pandemic, data from South Africa's National TB Prevalence survey showed that 58% of people who have TB disease have no symptoms. This means that only offering tests to people who have typical TB symptoms (cough, fever, night sweats, and weight loss) is inadequate to identify all people who have TB and to curb ongoing transmission.
As part of the TB Recovery Plan, routine testing should be offered to all people at high risk of TB disease. This should include people living with HIV, those who are close contacts of a person diagnosed with TB, and those with previous TB disease, regardless of whether they have TB symptoms, through a strategy called "Targeted Universal TB Testing" (TUTT). Additional strategies to increase testing are the launch of a new "TB Check" SMS helpline, the use of digital chest x-rays, and a urine-based rapid test for TB (in people living with HIV) that provides quick results in clinics.
Yet, despite national endorsement of this enhanced testing strategy, it is still not being adequately implemented on the ground. One of the interviewees said, "With TUTT we've had a little bit of a setback because of the shortage of GeneXpert cartridges, so we don't want to flood the labs now with requests for GeneXpert, so once that once that stabilizes, then the issues will be - will our facilities be able to cope with doing those tests?"
With the increase in the number of tests being conducted, it is vital to ensure that health facilities are adequately staffed and equipped e.g. with enough sputum booths, as well as GeneXpert cartridges and trained staff in labs to perform the tests.
2. After getting tested for TB, people need more support to receive their results and undergo treatment
Even for people who get tested, there are often delays in getting their results and sometimes they do not start treatment. Previously, a person who had a TB test done in a clinic would have to return in person for the result. Through a new strategy promoted in the TB Recovery Plan, laboratories are using SMS's to provide patients with their TB test results and ask them to return to clinics to start TB treatment where needed. Supporting people in their 6-month treatment journey, particularly people with drug-resistant TB who receive treatment for longer than that continues to be a challenge.
Socio-economic barriers to care, compounded by the COVID-19 pandemic, are not being adequately addressed and issues such as delays in processing South African Social Security Agency (SASSA) grants impact people's ability to afford transport to health facilities and missed days of work. In our interviews, participants mentioned that a multi-sectoral response to TB should include the Departments of Education, Social Development, Housing, and Environmental Affairs.
Other strategies that our interviews highlighted was the importance of a counselling package that gives support to people with TB that is broader than providing only medication. The duration of treatment and number of tablets are also adherence challenges. There is hope on the horizon in this regard, with shorter drug-resistant and paediatric drug-sensitive TB treatments becoming available, which will make it easier for people to complete their treatment.
3. We need to rethink how we approach TB Infection ("latent TB")
TB preventive therapy (TPT) is treatment given to someone who has been infected with TB, but who does not yet have TB disease ("latent TB"), in order to reduce the risk of progression to active TB disease. Despite data demonstrating the effectiveness and safety of TPT and clinical trials showing that shorter TPT regimens, such as 3HP (taking a once-weekly dose of Isoniazid and Rifapentine for three months), is as effective and less toxic than the current 6H (6 months of daily Isoniazid), which is associated with low completion rates, TPT scale up in South Africa continues to lag.
This could change with the recent release of the National Guidelines on the Treatment of TB Infection (on 9 March 2023) that includes new recommendations for shorter regimens including 3HP and 3RH (once daily dose of Rifampicin and Isoniazid for three months) and expands TPT eligibility criteria to all close contacts of people diagnosed with TB disease.
However, major implementation issues include rifapentine registration and procurement and sufficient health workers trained to roll out TPT to large numbers of people that have previously not received TB care. (As a starter - health workers reading this article can refer to the newly-released National Guidelines on the Treatment of Tuberculosis Infection).
4. Monitoring progress requires reliable data
The lack of quality data systems is an overarching issue, particularly compared to COVID-19. Without accurate data on how many people have been tested for TB, how many diagnosed with TB, and how many people start and then complete their treatment, we are fighting the TB pandemic with our eyes closed.
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The Western Cape's TB dashboard is an example that interview participants gave of a new initiative that provides data about the progress of the provincial implementation of the TB recovery plan, which is available to health workers and the general public. Community-led monitoring was another key area that could complement data systems and dashboards by providing key information on specific challenges experienced by people with TB such as TB stigma, and barriers to accessing health and support services. Communities can help signal to a range of stakeholders, from clinic committees to hospital boards to national political leaders that TB should be an urgent priority.
Looking beyond the TB Recovery Plan toward the new National Strategic Plan
We are at a moment where this bridging policy, the TB Recovery Plan, will soon be replaced by the National Strategic Plan. Our interviews have shown that simply releasing a policy at national level, while a step in the right direction, isn't enough. We need implementation plans to accompany it, which include training and adequate resources for implementation. This should include infrastructure to support wider TB testing, improved TB treatment support, better use of data to support implementation tracking, multisectoral collaboration, and a greater emphasis on creating mechanisms for accountability from provincial health departments who are the key implementors.
This emphasis on accountability means that we can all play a role in the success of South Africa's response to its leading cause of death. Let's talk more about TB, and about what it will take to ensure full implementation of policies because the suffering caused by TB demands greater action from all of us.
*Human, Nathavitharana, Giddy, Schoeman, and van der Westhuizen are all associated with TB Proof.
