Gesine MeyerRath Health Economics and Epidemiology Research Office HE 2 RO University of the Witwatersrand Boston University BEMF consolidation meeting 15 July 2011 Why TB financing ID: 736251
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Slide1
Issues in TB care
and financingGesine Meyer-RathHealth Economics and Epidemiology Research Office (HE2RO)University of the Witwatersrand/ Boston UniversityBEMF consolidation meeting 15 July 2011Slide2
Why TB financing?
HIV care and treatment is better planned and funded than ever before in South AfricaLots of cost and epi data is knownHIV care has ear-marked, national-level funds (Conditional grant)HIV care has own vertical system including own distribution channels for drugsTB diagnosis and treatment uses outdated tools and drugs and produces shoddy outcomesVery few cost data available, not much epi dataTB care is funded at provincial level via Equitable share, like all other provincial programmesTB care is highly localised and integrated into horizontal systemsSlide3
TB issues
UninfectedSuspectCaseCuredMDR
XDR
Cured
PREVENTION
DIAGNOSIS
TB TREATMENT
MDR-TB TREATMENTSlide4
TB prevention
UninfectedSuspectPREVENTIONSlide5
TB preventionEarly HIV diagnosis and ART initiation
HCT: 11.9 million people tested, but no link to TB diagnosis and treatment, not enough link to ARTART initiation at >200 CD4 cells/µl<350 for patients with TB since April 2010Initiation at <500 or irrespective of CD4 cell count?CMX and INH prophylaxis for HIV+vesIPT: INH prophylaxis for 6 mts irrespective of CD4 cell count after excluding active TBINH stock-outs as a result of badly planned demandINH/CMX combination possible but still in developmentSlide6
TB diagnosis
UninfectedSuspectCaseDIAGNOSISSlide7
TB diagnosis: Issues
Coverage: Case findingIntensified Case Finding (ICF) campaign: visited 41,000 families and screened 112,000 contacts since Feb 2011Sensitivity of current diagnostics (smear microscopy)Time to result (culture, LPA, DST)Cost of newer diagnostics (Xpert MTB/RIF, line-probe assay, drug-susceptibility testing)Slide8
TB diagnosis: Current situation
Current algorithm starts with smear microscopySmear microscopy of sputum technology more than 125 years oldSensitivity of smear microscopy (ability to find TB when it is there) is approximately 70%Sensitivity of smear microscopy in HIV+ population drops to 35-45%Current algorithm depends on culture Culture highly sensitive (considered ‘gold standard’)However, takes 2-6 weeks for resultsHigh rates of contamination, missing resultsSlide9
Possible solution: Xpert MTB/RIF
The Xpert MTB/RIF (Cepheid) test detects TB and rifampicin resistance (indication of MDR-TB) in less than 2 hoursThe sensitivity of Xpert MTB/RIF has been shown to be 86% in a SA demonstration studyHIV status does NOT affect sensitivity of XpertSlide10
Xpert roll-out: Planned timing
FAST SCALE-UP scenario: Full coverage by December 2012 (Ministerial mandate) SLOW SCALE-UP scenario: Full coverage by September 2013FAST SCALE-UP | June 2011 | Dec 2011 | Sept 2011 | Mar 2011 | Dec 2011 | Dec 2012SLOW SCALE-UP | June 2011 | Dec 2011 | Sept 2011 | Mar 2012 | Mar 2013 | Sept 2013
PHASES
| PILOT | FULL PILOT|HIGH CASE| GF XPERT | CONTROL
| DISTRICTS| ALL LABSSlide11
VISIT 3
VISIT 2
VISIT 1
GeneXpert
if negative
if positive
if unsuccessful
RIF resistant/
inconclusive
(MTB+/RIF+)
Sputum microscopy
TB culture
+ LPA +/- DST
TB diagnosis
HIV negative
Antibiotics
if resolved
if failed
if positive
TB diagnosis
if positive
TB diagnosis
Antibiotics
Chest X-ray
TB culture + LPA +/- DST
Chest X-ray
TB culture + LPA +/- DST
if positive
TB diagnosis
if negative
HIV status
HIV positive/
status
unknown
HIV positive/
status
unknown
HIV status
Antibiotics
TB culture + LPA +/- DST
if negative
if positive
TB diagnosis
Patients with suspected pulmonaryMTB
Xpert algorithm
Stop
Chest X-ray
Repeat GeneXpert
Sputum microscopy
TB culture
+ LPA +/- DST
if positive
TB diagnosis
Stop
Stop
HIV negative
HIV positive/
status
unknown
Antibiotics
if positive
TB diagnosis
if positive
TB diagnosis
Sputum microscopy
Antibiotics
Chest X-ray
Chest X-ray
if positive
TB diagnosis
if negative
HIV status
TB culture
+ LPA +/- DST
if negative
Stop
if resolved
if failed
Stop
Patients with TB history
Current guidelines
Patients without TB history
All patients
if un-
successful
HIV negative
HIV status
Antibiotics
TB culture + LPA
if negative
Chest X-ray
Stop
Stop
TB diagnosis
HIV positive
if negative
if positive
TB diagnosis
Sputum microscopy
if positive
Stop
if negative
Stop
if negativeSlide12
Xpert roll-out: Cost input
Cost itemCost in 2011 ZARTB diagnostics
Xpert MTB/RIF test
R190-220
Sputum microscopy (fluorescent microscopy)
R26
TB culture (liquid medium, growth)
R114
TB culture (liquid medium, no growth)
R87
Line probe assay (LPA) for all positive cultures
R189
Drug susceptibility test (DST) (first-line drugs only)
R519
Chest x-ray
R110
Antibiotic
trial
R19
Clinic visit: Nurse
R71
Clinic visit: Physician
R130
TB treatment
- First-line treatment (non- resistant)
R3,441
- Second-line treatment (non-resistant)
R6,806
- RIF monoresistance
R29,677
- INH monoresistance
R6,275
- Multi-drug resistance (outpatient care only)
R29,677Slide13
Xpert roll-out: Results of National TB Cost Model
Xpert leads to an increase of30% in TB cases diagnosed 76% in MDR cases identified39% in number of patients treated55% in the cost of the TB diagnostic programme32% in the outpatient cost of the TB treatment programmeif scaled-up fastUnder the Xpert scenario, 87% of diagnosed patients are diagnosed by Xpert83% are diagnosed after the first visitSlide14
TB treatment
UninfectedSuspectCaseCuredMDRTB TREATMENTSlide15
Patients with diagnosed pulmonaryMTB
Regimen 1(RHZE for 2 months, RH for 4 months)Patients without TB history(New cases)
Regimen 2
(RHZES for 2 months,
RHZE for 1 month,
RHE for 4 months)
Patients with TB history
(
Retreatment cases, old guidelines only
)
RHZE for 2 months,
RH for 4 months
+ OFL for 6 months
Patients with
INH mono-resistance
KNM, ETH, PZA, OFL+ TZ for 6 months
+ ETH, OFL+ TZ for 18 months
Patients with
RIF mono-resistance
Patients with
multi-drug resistant TB (MDR-TB)
KNM, ETH, PZA, OFL + TZ for 6 months
+ ETH, OFL + TZ for 18 months
+ Inpatient care until culture -Slide16
TB treatment: Non-resistant TBCommunity-based treatment
Good coverage, but low quality:Low completion rateLow cure rateHigh MDR and XDR rate2008 NHLS data: 6,219 MDR cases and 576 XDR casesCommunity-based system needs re-strengthening PHC revitalisation Community health-worker framework Intensified case-finding (ICF) campaignSlide17
MDR/ XDR-TB treament
UninfectedSuspectCaseCuredMDR
XDR
Cured
MDR-TB TREATMENTSlide18
MDR-TB treatment: Issues
Cost of drugs and monitoring of side effectsCentralised vs. decentralised care; inpatient vs. community careInfection controlPatient autonomyOperational challengesDrug supply chainsAdministration of daily injectibles for 6 monthsImproving outcomesCure rates between 33% and 45%Default rates up to 70%Death rate at Tugela Ferry after 1 year 75% (2005-2007)Slide19
MDR-TB treatment: Current situation
MDR-TB care differs vastly by provinceKZN: mostly community care; GP: exclusively centralised careCurrent guidelines prescribe inpatient care until culture negative (2 cultures taken 30 days apart)currently at specialised MDR/ XDR hospitals (9 specialised, 11 decrentralised units)73% of known MDR/ XDR cases in 2008 were hospitalisedon average 4 monthsnot enough capacity (1,854 beds in Feb 2010), waiting listat average cost per patient-day equivalent (R 1,069) 4 months cost R163,000Slide20
MDR-TB treatment: Decentralised care
Decentralisation plan for MDR care approved by National Health CouncilRationale:Low capacity and infection risk while waitingNosocomial transmission of MDR/XDR-TBPatients abscond due to lack of recreational facilities, family responsibilities and lack of incomeEven if ambulant, monthly trips to centralised hospitals are difficultDecentralised care is uncoordinated and chaoticSlide21
Planned guidelines:MDR-TB treatment at MDR units in TB hospitals (district and sub-district level) and at PHC clinicsInpatient treatment for 8 weeks or until
2 consecutive sputum smears negativeFollow-up at community level by PHC staff or mobile units and DOTS plus supportersMDR-TB treatment: Decentralised careSlide22
Summary: Cost issues IVery few data available
Cost of diagnosis modelledCost of treatment: 1 study of community-based treatment (Sinanovic et al Int J TB Lung Dis 2003)1 study on cost of care for HIV-co-infected patients (Cleary et al Cost Effect Resource Alloc 2006)No data on cost of MDR careStudies on real cost of Xpert roll-out and on cost of MDR-TB inpatient care plannedSlide23
Summary: Cost issues IIICF
: more suspects (target: 10% growth every year)Xpert: 30% more cases, 76% more MDR cases, 39% more patients on treatmentHigher costICF: lower smear sensitivity in suspectsXpert: more cases treated, lower transmission, less new cases (including of MDR-TB)MDR/XDR-TB treatment decentralised with less inpatient careLower cost