Patients and TB: Improving treatment outcomes through a patient centred approach and

access to new treatments

5th TB Symposium – Eastern Europe and Central Asia Ministry of Labour, Health and Social Affairs of Georgia

and Médecins Sans Frontières

22- 23 March , 2016 , TBILISI , GEORGIA

Addressing adherence issue in high-burden MDR-TB countries: example from Belarus

Alena Skrahina The Republican Research and Practical Centre for pulmonology and TB, Minsk,

Belarus

TB

MDR-TB TB mortality

Belarus TB epidemiology

2015, 4.1

0

2

4

6

8

10

12

14

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

2015, 33

0

10

20

30

40

50

60

200420052006200720082009201020112012201320142015

2015, 66

2015, 33

0

20

40

60

80

100

2004 20052006 2007 20082009 20102011 20122013 20142015

previously treated

%

new

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

LTFU in regions, 2015, non-MDR

0.7%

0.2%

1.7%

1.0% 1.1% 1.1%

1.6%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

Minsk city Brest reg Vitebsk reg Gomel reg Grodno reg Minsk reg Mohilev reg

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

LTFU in 2010-2015, non-MDR

2.2% 1.9% 1.9% 2.0%

1.7%

1.0%

4.8% 4.2%

2.7%

1.3% 1.9% 1.1%

8.4%

5.3%

1.6%

4.4% 4.6%

1.5%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

2010 2011 2012 2013 2014 2015

New Relapses Other PT

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

Outcomes of MDR-TB treatment, 2011-2013

43%

45%

41%

15.5%

10%

10%

8%

3.8%

24%

22%

21%

21.7%

11%

11%

10%

8.6%

11%

11%

12%

9.0%

1%

8%

41.4%

2011

2012

2013

2014

Cured Completed Failure Death LTFU Not evaluated

2347

2528

1618

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

Pre-

Treatmentat

LTFU

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

MDR-TB patients demographic characteristics

Social group Proportion

Unemployed 25.2%

Homeless 1.1%

With previous imprisonment history

2.1%

Alcohol addicts 15.3%

HIV-infected 5.8%

Patients living in rural area 37.1%

Skrahina A. et. all, Bull World Health Organ, 2013

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments

Tuberculosis Symposium – Eastern Europe and Central Asia Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

ID department

TB treatment + cART

Discharged

Outpatient follow-up cART + TB tretament

OST

Methadone cART TB treatment

+ social support

Management of TB/HIV patient in Western Europe

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

ID Hospital

TB Hospital

Discharged

MTB+

Consultation of HIV specialist

TB outpatient unit AIDS Centre

OST???

Social support???

Management of TB/HIV patient in Eastern Europe

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

Improving adherence of TB patients

• Identify potential risk factors and targeted intervention

• Extensive adherence counselling

• Provision of Enablers: Food package and transport ticket

• Aggressive and immediate management of drug AE

• Screening for co-morbidities (HIV) and other related conditions (IDU, alcohol abuse) and ensure adequately treated

• Screening for mental health problems and ensure adequately treated

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

MDR-TB Consilium (Expert Board) 1 National, 6 Regional and 1 Prison MDR-TB Consiliums

• M/XDR-TB, HIV/TB, Child TB, Difficult-to-treat TB

All registered MDR-TB cases

Adherence issues

Management of co-morbidities

Management of AE

Alcohol abuse, IDU

Mental health problems

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments

Tuberculosis Symposium – Eastern Europe and Central Asia Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

Health care financial problems

• Financing - the number of beds

• Lack of mechanisms for

paying supplementary benefits to primary HCP

social support to outpatients

• Unnecessary long term hospitalization:

61 days S-TB

153 days MDR-TB

Weak out-patient care

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

In-patient vs. out-patient

In-patient care: Out-patient care:

• Isolation of sm+/cult+ • Daily observation and more

intensive management • No patient’s costs (transport,

food, etc.)

• Need for IC • Expensive for HC system • Isolation from family • Inability to work • Cross contamination

• Not expensive for HC system • No cross contamination • Ability to work • Living with families

• Need for sm- sputum • Costly for patient (food, transport) • Poor adherence and LTFU

– alcoholics, IDU, former prisoners – Drug side effects

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

Mogilev project

Actions

• TB beds

• MoH approved new contracts for PHC staff, i.e. payment for every visit

Results

• early discharge

• treatment outcomes – Incl. ↓LTFU

• developing new financial mechanisms for ambulatory strengthening

• saving money and resources

Funds reallocation from TB hospitals to PHC settings

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

NTP measures to increase adherence

• aDSM

– CEM: HIV-M/XDR TB (2012), LZD (2014), BDQ (2015)

• HIV testing in all TB patients

• cART+Co-trimaxasol in all HIV/TB

• MST for IDU HIV/TB patients

• Psychiatrist (narcologist), psychologist – in each TB hospital

• Mandatory transportation freed prisoners with TB

• Provision of Enablers (food packages) at out-patient phase for each TB patients from state budget (2015)

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

VOT procedure

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

IV central port for patients on new drugs

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières

Future steps

• Change financial mechanism • Stronger motivation of staff and patients

• Close collaboration with Ministry of Labor and Social Protection • Social support from government (transport) • Work permission for TB patients

• MST in TB DOT facilities • Management of alcohol abuse to incorporate in TB treatment • Psychological support at out-patient settings • Scaling up eDOT (VOT)

Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia

Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières