Examining the cost of community-based tuberculosis treatment in South Africa.

SETTING: While South Africa has improved access to tuberculosis (TB) treatment and care, the 2015 treatment success rate for multidrug-resistant TB (MDR-TB) remains low, at 55%. Community-based TB treatment and care improves patient retention compared to the standard of care alone.OBJECTIVE: To assess the cost of a USAID-funded community-based TB model in Nelson Mandela Bay Health District (NMBHD), Eastern Cape Province, South Africa compared to the national standard of care alone.DESIGN: We estimated the cost of community-based DR-TB treatment and adherence support compared to the standard of care alone.RESULTS: Average overall costs were US$2827 lower per patient on the community-based model than the standard of care alone.CONCLUSION: The per-patient cost of the community-based model is lower than the standard of care alone. Assuming the costs and effects of a community-based model implemented in NMBHD were observed at a larger scale, implementing the model could reduce overall health system costs.

Treatment of drug-resistant tuberculosis with bedaquiline in a high HIV prevalence setting: an interim cohort analysis.

BACKGROUND: South Africa has a large burden of extensively drug-resistant tuberculosis (XDR-TB); only 15% of XDR-TB patients have successful outcomes. OBJECTIVE: To describe the safety and effectiveness of bedaquiline (BDQ) in the South African BDQ Clinical Access Programme. DESIGN: An interim cohort analysis. RESULTS: Of the first 91 patients enrolled between March 2013 and July 2014 (with follow-up until August 2014), 54 (59%) were human immunodeficiency virus (HIV) infected. The median CD4 count was 239 cells/µl, and all patients were on antiretroviral therapy (ART) at initiation of BDQ; 33 had XDR-TB, 41 were pre-XDR-TB with fluoroquinolone resistance and 17 were pre-XDR-TB with resistance to an injectable. Of the 91 patients, 58 (64%) had completed 24 weeks of BDQ, 28 were still on BDQ, 3 were lost to follow-up, 1 had died and 1 had BDQ withdrawn following atrial fibrillation. Of the 63 patients with 6 months follow-up, 48 (76%) had either culture-converted or remained culture-negative after initiation of BDQ. QTcF was monitored monthly and exceeded 500 ms in three participants; this resolved in all three. CONCLUSION: Interim safety and culture conversion outcomes for patients accessing BDQ in South Africa, including HIV-infected patients on ART and patients with pre-XDR- and XDR-TB, suggest that BDQ may be both efficacious and safe.

Successes, challenges and lessons from a novel deployment of Xpert(®) MTB/RIF at a major South African public event [Short Communication].

In a mobile deployment of Xpert(®) MTB/RIF (Xpert) at the public event for 2012 South African World TB Day, Xpert testing was offered to tuberculosis (TB) symptomatic clients from gold mining and surrounding communities. Considerations before implementation included effective TB symptom screening; safe, effective sputum collection; uninterrupted electricity supply; stringent instrument verification and provision of on-site results. Public event Xpert testing is feasible; however, the case-finding rate was very low (0.7%). We recommend exploring enhanced symptom screening algorithms to improve pre-test probability, cost-effectiveness analysis, exploring alternate electrical fail-safes and on-site data connectivity and improving management of client expectations.

Development of a health programme in a peri-urban informal settlement in Besters, KwaZulu-Natal.

OBJECTIVES: The demographic, socio-economic and environmental status of the peri-urban informal settlement of Besters and its inhabitants' health, welfare and disability profiles were investigated for the development of a community-based health intervention programme. STUDY DESIGN: A cross-sectional study using a structured household questionnaire assessed community health status in July 1991 in order to identify specific health and development needs through focus group discussions and community consultations. A health and development programme was established during 1992. Community participation in this programme was then assessed by measurement of the components of the health and development programme, categorised as inputs (resources), processes (activities), outputs (effects) and outcomes. SETTING: Besters, an informal peri-urban settlement north of Durban, KwaZulu-Natal. SUBJECTS: Residents of Besters. RESULTS: The demographic, environmental and morbidity profiles of Besters were consistent with both South African and international studies of informal communities. Patterns of health service utilisation reflected inappropriate use of the tertiary hospital in the city centre, grossly fragmented patterns of utilisation--both for preventive and curative care and for antenatal and maternity services--and, finally, a discordance between community health needs and ability to pay for services. The interaction between input, process and output measures of community participation are discussed. CONCLUSION: Integration of health service provision with other infrastructural development, based on community perceptions, enhances health development and community participation. Important lessons emerged about the strengths and limitations of community participation and its relevance for other communities.

Vitamin A deficiency among children in a periurban South African settlement.

Preschool children (aged 3-6 y) who were living in an informal settlement within metropolitan Durban, South Africa, were assessed for vitamin A status. The serum retinol concentration of 169 children tested was 0.73 +/- 0.26 mumol/L (mean +/- SD). Nine children (5%) had vitamin A deficiency (< 0.35 mumol/L) and 75 children (44%) had low vitamin A concentrations (< 0.70 mumol/L). Conjunctival impression cytology (CIC) in 185 children revealed that 18% had poor vitamin A status as defined by two abnormal conjunctival specimens. The CIC test was a feasible and reproducible method; however, it correlated poorly with the traditionally accepted serum retinol threshold of deficiency in this population where overt vitamin A deficiency is not prevalent. This survey demonstrated that regardless of the measurement tool, there is a prevalence of subclinical vitamin A deficiency in this typical periurban informal settlement and accordingly we suggest that these children should be targeted for vitamin A-intervention strategies.

Establishing priorities for advocacy in South African Health.

PIP: To develop an appropriate health policy agenda, the National Progressive Primary Health Care Network (NPPHC) and the South African Health and Social Services Organization (SAHSSO) conducted situational analyses in 4 areas: an informal peri-urban area within the Durban functional region in Natal, a rural area in the Mhala-Mapulaneng district in the North Eastern Transvaal, the informal settlement of Botshabelo in the Orange Free State, and a dense township dwelling in Soweto. The analyses were based on interviews with health workers and community leaders, a national survey, and a questionnaire for health service administrators. All 4 areas were characterized by poverty, unemployment, low educational levels, lack of a clean water supply or refuse removal system, housing shortages or overcrowding, and political violence. Preventable diseases, such as water-borne diarrhea and malnutrition, cause substantial morbidity, yet health services tend to be inaccessible, distributed inequitably, of poor quality, and with unclear administrative structures. Community members interviewed indicated that clinic fees were too high, especially given the low quality of care, and there was a general mistrust of the competency of doctors and nurses. There was a lack of consensus on the meaning of community participation; some viewed it as a vehicle for empowerment, while others felt the strategy would be exploited as a means to deny government assistance. Overall, respondents were supportive of a greater role for community health workers and more involvement on the part of nongovernmental organizations. A priority, at present, is attention to the many socioeconomic factors that are compromising the health of black South Africans and overshadowing the rationalization of health services.^ieng

Making district health care a reality in KwaZulu Natal

Management training has been recognised as a priority in the transformation of health care in South Africa. This report documents efforts to strengthen management capacity through a development programme in eight emerging districts in KwaZulu Natal. It is not a formal evaluation; but rather a description of the activities