Sticking to treatment
Adherence to DR-TB therapy is essential for treatment to be successful. Poor adherence may result in unsuccessful treatment outcomes, and the infection of other household and community members. In addition, resistance to an increased number of drugs can develop.
At the MDR-TB think tank held in Johannesburg in early April this year, Professor Jose Caminero from the World Health Organization repeatedly emphasised that poor adherence, which results in default, is a major challenge to the South African MDR-TB programme. According to the most recent available South African MDR-TB programme data on treatment outcomes (2010), the default rate for the country is 19.4%. Three provinces in particular have high default rates; the Northern Cape (33.7%), Limpopo (31.4%), and the Western Cape (27.1%).
We need to interrogate why almost a quarter of our DR-TB patients are defaulting, and adjust our way of working to increase adherence and improve the probability of treatment success.
Adherence to DR-TB therapy is not easy. It includes a daily injection for at least six months of treatment and ingesting a large number of pills on a daily basis for almost two years. The high pill burden increases in patients who are also receiving anti-retroviral treatment. Moreover, many patients experience side effects as a result of the medication, including dizziness, hearing loss, nausea and vomiting, diarrhoea and confusion. These side effects make getting through each day difficult and the temptation to miss treatment and default alltogether is high. Thus it is imperative that these patients are supported through their treatment journey.
Many patients’ experience of DR-TB services does little to enhance adherence. Healthcare workers can be uncaring and appear to be unaware of the consequences of their actions. Little attention is paid to privacy or compassion when informing patients of their diagnosis of MDR-TB – this is usually done in front of others, or in a consulting room
“DR-TB therapy is not easy. It includes a daily injection for at least six months of treatment and ingesting a large number of pills on a daily basis for almost two years.”
closed by a curtain from which every word can be heard. While we should be cautious not to shroud TB in secrecy as we have done with HIV, the social isolation, fear and stigma is distressing and humiliating.
Healthcare workers who fail to educate patients about the disease, the difficulties of adherence, each individual patient’s responsibility to take their medication and the importance of the support of a household or community member, further hamper the chances of successful treatment. Indeed, the provision of counselling is a key aspect of DR-TB treatment; ongoing adherence counselling and psychosocial support throughout treatment are emphasised in the South African DRTB guidelines. This includes counselling not just for the patient, but also for family and household members. Ideally, counselling should be provided through structured sessions by trained and well-supported counsellors. Whether counselling is receiving the focus needed across South Africa, however, is unclear.
While we await the availability of new, more successful drugs and treatment regimens for DR-TB, healthcare workers are able to assist the chances of successful treatment using a few effective tools: Taking time to educate the patients about their disease and the importance of adhering to treatment; helping patients realise that they are responsible for ensuring that the treatment is successful by taking their medication every day; and encouraging patients with DR-TB to find a ‘buddy’ in the community who will both support and ensure that they are taking treatment as prescribed daily.
Loveday is a senior scientist at the Medical Research Council. Padayatchi is with the Centre for the Aids Programme of Research in South Africa.