Defaulting on treatment – where are we?

Defaulting on treatment – where are we?

Default from treatment for drug resistant TB (DR-TB), (now classified as lost to follow-up), defined as interruption of TB treatment for two or more consecutive months, is a problem that is reported by TB control programmes globally. Completion of treatment for DR-TB is particularly difficult since treatment duration is long (at least 18 months), involves a large number of pills, and a painful injectable agent in treatment regimens characterised by significant side effects. Default from treatment impacts on attainment of treatment success (cure and treatment completion) and is associated with high mortality post treatment. Furthermore these patients continue to contribute to community transmission of DR-TB. This major driver of the epidemic since they may stop treatment before sputum conversion or revert back to infectiousness given their incomplete treatment status.

Nationally the default rate was estimated at about 18% over the period 2007-2010. However, high rates have been consistently reported in various settings across the country. Between 1992 and 2002 the default proportion peaked at 40% in the West Coast Winelands, with a recent analysis in the same area reporting a 27% default rate. Analysis of outcomes of DR-TB patients in eight provinces (excluding the Western Cape Province), between 2000 and 2004, and a study among DR-TB patients in KwaZulu-Natal (2000-2003), both found a 21% default rate. Recent data from a study in KwaZulu-Natal reported a 14% default rate at four sites in the province. In a decentralised community based DR-TB programme, in Khayelitsha, Cape Town, default from treatment over the period 2007 to 2011 was 31%. This higher rate of default in Khayelitsha (compared to KZN and recent data from the Winelands) is probably due to treatment of patients who are clinically less ill (since treatment can be initiated earlier in the decentralised community based programme), and would therefore be more likely to default when compared to sicker patients seen where treatment is more centralised.

Studies have shown that default from DR-TB treatment is driven both directly and indirectly by interplay of individual, socio-demographic, economic, clinical and programmatic factors. Amongst the myriad of risk factors known to be associated with default from DR-TB treatment, in South Africa, young age, being male, poor health-care worker attitudes, residing in the Eastern Cape or Western Cape provinces, alcohol and substance abuse, previous treatment for DR-TB, and economic instability have been identified as risk factors for default in various settings. Analysis of data from Khayelitsha has also shown that default occurs early in treatment and persists throughout the treatment period.

A recent systematic review noted that current interventions for supporting patients on DR-TB treatment are poorly described and are based on weak evidence, a finding consistent with the high levels of default seen in South Africa. Lower default rates were associated with engagement of community health workers as Directly Observed Treatment (DOT) supporters, provision of DOT throughout treatment, provision of patient education, and small cohort sizes (<100). The review rightly advocates for sound research into these relatively low cost and promising strategies to address the challenge of poor retention of patients on treatment for the required period3. With exception of small cohort sizes, these strategies could easily be integrated into current health practice in South Africa, given the already existing infrastructure of community health workers. Ongoing monitoring and support of health facilities is also crucial. Occurrence of default throughout treatment highlights the need for early initiation and support for patients throughout treatment. Strategies to identify and support patients as early as possible after they interrupt treatment – prior to meeting the definition of default at two months off treatment – may further improve retention in care.

While more effective treatment retention strategies are vital in reducing default from DR-TB treatment, it is undeniable that shorter and less toxic treatment regimes that exclude the painful injectable agent are critical in addressing this problem and the DR-TB problem as a whole. Therefore efforts to reduce default should also be directed at improving treatment regimens.

Moyo and Cox are with Médecins Sans Frontières in Khayelitsha, Cape Town.

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5 Responses to “Defaulting on treatment – where are we?”

  1. anita s

    Good Afternoon
    What infectious risk does a person who has defaulted tb treatment pose to family, friends and colleagues.Is it advised to return to work while defaulting on treatment.If so,what precautions should colleagues take.

    Reply
    • Nikiwe Ndaba

      The risk to family friends and colleagues is contracting resistant strains of Bacilli.
      As much as breadwinners need money to feed their dependents, it is not advisable to default medications and still go to work, as this puts colleagues at risk of contracting the bacilli or the drug resistant Tubercle.
      Colleagues need to support the and advice to adhere to medications as well as help to supervise if agreeable
      The sick colleague can be advised to wear a musk to protect his/her mouth, stick to cough etiquette and get medical counseling to voice out challenges faced that leads to defaulting the medication.

      Reply
  2. Faiza

    If the patient is compliant( is always coming for refill and never talk that she is not taking her medication) but not adherent to treatments(stop taking her treatment from the 8th month of treatment to 14th month) then culture reverted positive. we did DST( Resistance to RMP,INH,S-MDR TB)- fortunately has same resistance pattern. what is the treatment outcome for this patient? is she a treatment failure or Defaulter?
    Thanks in advance……

    Reply
  3. Casino

    Good Day
    I would like to report a defaulting patient, he stays with more than 5 members of the family and my worry is infecting them all especially the kids.

    Please help with relevant details

    From: Port Elizabeth, Walmer (Eastern Cape)

    Thanks

    Reply
  4. Thobeka swebhe

    Hi i have a problem my daughter defaulting his treatment,where can i get help ?i stay at cape town khayelitsha

    Reply