Patient-centered treatment of tuberculosis in Tanzania

Tanzania is one of the 22 high-burden countries with respect to tuberculosis (TB) incidence. Approximately 62’000 cases are detected every year compared to 11,753 in 1983. A recent study suggests that 35% of smear-positive TB patients are HIV-positive. Hence, TB is one of the most common causes of death among HIV/AIDS patients.

Although treatment for tuberculosis has been available free of charge in Tanzania, the disease is still one of the most common causes of death. Causes are delays in detection and treatment as well as patients adherence. In order to improve access to TB treatment and hence adherence and cure rates, the Novartis Foundation for Sustainable Development in cooperation with the Tanzanian National Tuberculosis and Leprosy Program (NTLP) developed and introduced an innovative initiative, placing the patient at the center of treatment.

Simpler treatment – regimen at health facilities or at home

Thanks to the country-wide drug donation of Novartis, the NTLP introduced a new treatment regimen reducing the treatment period from 8 to 6 months in 2006. The WHO-recommended treatment, called Directly Observed Treatment Short-course (DOTS), requires patients to take their drugs under daily observation at a health facility in order to prevent resistance against rifampicin. In light of overburdened health systems in many developing countries, this approach is, however, often very difficult to conduct and also puts a burden on patients as they have to walk long distances to the next health facility.

To overcome these obstacles, the Novartis Foundation and the NTLP, supported by organizations such as the Dutch KCNV, combined the introduction of the new regimen with an innovative approach called patient-centered treatment (PCT). PCT gives the choice to patients as to whether they want to take the treatment at home or at a health facility. DOTS is respected in the sense that a patient always needs a treatment supporter. Under home-based treatment, this can be the spouse, a family or community member. In the case of health facility-based treatment, it is the healthcare staff. During the intensive phase, patients and their supporters under home-based treatment have to come both every week with the empty blister pack to collect a new blister with the combination tablet. At a later stage, they only have to come back every two weeks.

Sensitization, training and intensive supervision

Such an approach not only demands proper information and instruction of treatment supporters, but also regular supervision to monitor treatment successes and failures as well as potential resistances. The two partners tested the approach in three pilot districts – one urban and two rural. Healthcare personnel was trained in PCT, monitoring systems were developed and made functional, and sensitization campaigns have been carried out. These campaigns carried out in 2007 aimed at informing people about causes and symptoms of TB as well as the new treatment regimen, where to receive treatment free of charge and how to take it. The ultimate goal was to create demand for TB treatment and make people with cough persisting for more than 2 weeks come forward for diagnosis. Next to brochures, posters and wall paintings, the campaigns entailed radio and TV spots as well as road shows in villages

Results so far and next steps

A cohort analysis and a cross-sectional survey revealed that 88% of the TB patients chose home-based treatment. This figure reflects the high demand for a treatment approach that does not oblige the patient to come to the health facility every day.

Moreover, the evidence suggests that PCT does not harm treatment success (completion) rates – on the contrary: the rate improved from 72% in 2005 (the year before PCT was introduced) to 77.5% in 2007. Equally, the rate of unfavorable treatment outcomes was reduced from 28% to 22.5%. Based on this first evidence and given the fact that health services are overburdened, the NTLP decided to rapidly scale up the PCT in all of Tanzania.

Future challenges are to consolidate the successful introduction of PCT; i.e. by mainly putting emphasis on proper instruction of treatment supporters and their supervision through the healthcare, as to avoid resistances.