BYLINE: eRIC GOEMAERE
The Cape Times editorial on March 14 suggested that community-based approaches to fighting tuberculosis should be expanded to other areas of health care such as HIV/Aids.
In fact, HIV/Aids care programmes have been quick to adopt the lessons of community-based treatment. Given the number of people with HIV/Aids in need of care and treatment, there was no choice. In South Africa up to 700 000 people are estimated to be in need of anti-retroviral treatment. This target will never be reached if there was an insistence that all patients must receive treatment from doctors in hospitals.
There are not enough doctors, hospitals are overcrowded as it is, and patients cannot afford the time or money to travel long distances on a regular basis to get to a hospital. Community-based care is the only way to go.
To give one example, Medecins Sans Frontieres’s experience in supporting HIV/Aids care in Khayelitsha is entirely dependent on clinic-based, community-supported services. Using this approach over 5 500 people are receiving anti-retroviral treatment today. A hospital-based service would have reached saturation a long time ago. And still this represents only a third of the number of people who will need treatment in the coming three years. We need to find ways of pushing HIV/Aids even further into the community.
While community-based programmes have been essential in the fight against HIV/Aids, these programmes have departed from the TB approach in one essential way. In the HIV world, patients are seen as active participants in the provision of care, and are supported to take responsibility for their own health, and with excellent results. This is a lesson that the TB world is only just beginning to learn.
People who take anti-retrovirals are not passive swallowers of pills. Thanks to effective treatment literacy programmes, they understand fully the importance of adherence to medicines, know names of the drugs they are taking, the common side-effects of these drugs and available alternatives. They can speak quantitatively about their immune status (CD4 count) and how well the drugs are working (viral load). They also support each other in taking their medicines.
The effectiveness of this patient-centred approach is demonstrated by the fact that adherence to treatment in Khayelitsha, and many treatment programmes across Africa, is as good as anywhere in the Western world.
In contrast, the traditional approach to tackling TB could hardly be more different. Treatment, which lasts at least six months, is based on “directly-observed therapy” in which patients are instructed to come to health facilities to take their medicines under daily supervision. Patients are not only reduced to being passive swallowers of pills, they are not even trusted to do so by themselves.
Partly thanks to the good results from HIV programmes, the TB world is starting to cautiously relax the requirement of directly observing patients and community-based strategies are slowly being adopted. But in the face of MDR- and XDR-TB, the immediate response has again been one of patient control, with measures such as involuntary detention of patients tabled as policy priorities.
The advice given by international experts to deal with the increasing problem of MDR- and XDR-TB is to follow the example of successful control programmes in Eastern Europe, where the MDR-TB epidemic is predominantly perceived as a “man-made disaster” resulting from patients not properly taking their drugs. …