The South African Tuberculosis Care Cascade: Estimated Losses and Methodological Challenges

Abstract

BackgroundWhile tuberculosis incidence and mortality are declining in South Africa, meeting the goals of the End TB Strategy requires an invigorated programmatic response informed by accurate data. Enumerating the losses at each step in the care cascade enables appropriate targeting of interventions and resources.MethodsWe estimated the tuberculosis burden; the number and proportion of individuals with tuberculosis who accessed tests, had tuberculosis diagnosed, initiated treatment, and successfully completed treatment for all tuberculosis cases, for those with drug-susceptible tuberculosis (including human immunodeficiency virus (HIV)–coinfected cases) and rifampicin-resistant tuberculosis. Estimates were derived from national electronic tuberculosis register data, laboratory data, and published studies.ResultsThe overall tuberculosis burden was estimated to be 532005 cases (range, 333760–764480 cases), with successful completion of treatment in 53% of cases. Losses occurred at multiple steps: 5% at test access, 13% at diagnosis, 12% at treatment initiation, and 17% at successful treatment completion. Overall losses were similar among all drug-susceptible cases and those with HIV coinfection (54% and 52%, respectively, successfully completed treatment). Losses were substantially higher among rifampicin- resistant cases, with only 22% successfully completing treatment.ConclusionAlthough the vast majority of individuals with tuberculosis engaged the public health system, just over half were successfully treated. Urgent efforts are required to improve implementation of existing policies and protocols to close gaps in tuberculosis diagnosis, treatment initiation, and successful treatment completion.

Capture and visualization of live Mycobacterium tuberculosis bacilli from tuberculosis bioaerosols

“…TB control is almost entirely predicated on the treatment of active disease. However challenges posed by the long duration of standard chemotherapy (2,3), delayed and missed diagnoses (4,5), and failure to retain patients in treatment programmes, mean the goals of global TB eradication remain aspirational (6). The propagation of multi-drug resistant (MDR) disease further imperils this approach; an assessment reinforced by growing evidence of the primary transmission of MDR Mtb strains (7)(8)(9)(10)(11)(12) and the knowledge that MDR-TB now accounts for more than one-quarter of all antimicrobial resistance (AMR) cases annually.…”

Improving management of tuberculosis in people living with HIV in South Africa through integration of HIV and tuberculosis services: a proof of concept study

“…It is a well-known phenomenon in TB care in South Africa that not all patients with presumed TB (presence of TB symptoms) progress to testing and treatment, due to challenges of patient adherence, as well as shortcomings on the healthcare system [19]. We found similar percentages of patients ‘lost-to-follow-up’ in the pre-treatment care cascade, from screening to treatment initiation, of patients who were cared for by HIV and TB service providers.…”

“…As we could see from our own results, patient moving between different facilities is a common practice – nearly half of the patients who started TB treatment at our study sites were transferred in, having been diagnosed with TB at another facility (clinic, hospital or a private general practitioner). Such movements, however, especially in patients who move out without giving or being able to give notice to the provider in advance, are unfortunately difficult to trace [19, 29, 30]. …”

“…First, patients who are screened for TB symptoms and found to be symptomatic are inconvenienced by the need to wait for the TB service, having already waited in line to see the HIV provider when they arrived at the facility. Anecdotal evidence suggests that some patients lose their patience and leave the facility before they see the TB provider to obtain their sputum test [19]. If these patients have TB, this is a lost opportunity for early diagnosis and treatment.…”

Variation in HIV prevalence and the population-level effects of antiretroviral therapy in reducing tuberculosis incidence in South Africa

“…[1,2] Despite these and other public health efforts, TB remains a leading cause of death in SA, [1] and at the current rate of decline, SA will not reach the 2035 targets of the End TB Strategy. [3] National-level observational and mathematical modelling studies suggest that further scale-up of ART could yield substantial reductions in TB incidence and mortality over the next two decades. [4,5] The effect of ART on halting and reversing local TB incidence depends on the extent to which TB (and transmission) in the population is attributable to HIV infection.…”