S ..Doltu,1.L ..Severin,1.A ..Ciobanu,2.L ..Domente,2.C ..Celan,3.V ..Soltan3.
1.Act.for.Involvement;.2.National.TB.Programme,.Chiril.Draganiuc.Phthisiopneumology.Institute;.3.Centre.for.Health.Policies.and.Studies Consolidated Action Plan, area of intervention 7
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Republic of Moldova |
ists directly or via an insurance scheme. As insurance could be accessed only if the patient had an identification card, the NGO helped some patients to re-establish their cards.
A plan was made for continuing DOTS, e.g. in an office or through a DOTS provider from an NGO at a location speci-fied by the patient. Soon after the beginning of the project, 35 homeless patients had been identified; thus, assisting them was beyond the capacity of one DOTS supporter. Therefore, when possible, the plan specified an alternative location such as a polyclinic, where adherence was monitored once a week. The DOTS supporter visited patients who refused to go to a polyclinic at the places they frequented, spending half a day in the polyclinic and half doing DOTS outreach.
On the questionnaires, the homeless people indicated two to five locations at which they could usually be found, such as markets, old churches or, in wintertime, abandoned build-ings.
Material support was provided by the Global Fund, indi-vidual donations and a donation from the Church. To raise funds for warm meals for homeless people during the winter months, sales were organized, at which people could give a donation in symbolic exchange for an apple. The action was a success: people started bringing food and clothes to the NGO and, later, virtual donations online via Facebook.
By the end of 2014, TB case identification among homeless people had increased their access to rapid TB diagnostics with GenExpert. MDR-TB patients in this group are enrolled in treatment with second-line drugs. In 2014, 1147 homeless people were interviewed and informed about TB, and 299 (26%) with presumptive TB were tested. TB was confirmed in 58 cases (12 females and 46 males), representing 19.4%
of those found positive by screening. Thus, the TB incidence rate among homeless people is 50 times higher than the aver-age rate in the country (5056 per 100 000 homeless versus 99 per 100 000 in the general population). Of the 58 patients identified, 31 (53.4%) have completed their treatment, 7 were lost to follow up (12%), 3 died (5.2%), and the other 17 are still on treatment with second-line drugs (29.3%).
More than 120 social assistants were trained in case man-agement of TB in homeless people and on international strategies in this area. One- to two-day training courses included general information on TB (signs, routes of trans-mission and referral), infection control, international rec-ommendations for TB in the homeless and the local context in Chisinau. The courses included group work and case stud-ies. The project improved social workers’ awareness about
TB and engaged them in activities to increase treatment adherence by the provision of social support, such as a one-time allowance and help in obtaining disability status. A few homeless persons were reintegrated into their families with the help of the social services.
Outcomes
During the project, a sustainable dialogue was established between the municipal health services and the social ser-vices to prepare a specific action plan for the homeless.
Homeless people received better access to TB diagnostics and treatment, including rapid diagnostic tools and sec-ond-line drugs. In the past, this category of patients was refused MDR-TB treatment because they could not continue ambulatory care.
The initiators of the project raised funds to initiate a small sociological study of homeless TB patients, including not only social determinants but also other infectious and non-infectious diseases. The preliminary results show a very high percentage of alcohol dependence and infection with HIV and other sexually transmitted diseases.
Important factors for success
The experience gained by the NGO during the project was the basis for proposals to the NTP for modifications to the national protocol on TB in adults (http://old.ms.md/pub-lic/info/Ghid/protocolls/pcn123/). Hospitalization criteria were revised to include the status of homeless person and to allow discharge from the hospital only if the conditions for continuation of outpatient treatment are met. In the same protocol, homeless people are considered a priority for test-ing with GenExpert.
Ensuring sustainability
TB diagnosis and treatment for homeless people are free of charge; first-line drugs are covered by funds from the national insurance company and second-line drugs by the Global Fund. The new programme of the NTP should include a sustainability plan and full funding from the State budget after 2017.
Social problems faced by homeless people are barriers to successful TB treatment. Addressing them required effective dialogue with municipal health services and social services, which was established in this project and must be main-tained. Regulations on living in a temporary residence for homeless people are meant to provide equal access and to prevent discrimination; these are under revision.
50 | Good practices in strengthening health systems for the prevention and care of tuberculosis and drug-resistant tuberculosis
Potential for scaling up and future areas of development
The social workers suggested joint training with family doc-tors when funds become available.
There remains an urgent need to create proper conditions for the health and social support of homeless people with TB in
order to provide a comprehensive continuum of care. These include TB treatment in combination with substance abuse treatment programmes and programmes to strengthen treatment adherence and social reintegration.
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Republic of Moldova |
Background
The Republic of Moldova has very high burdens of TB and MDR-TB. MDR-TB represents 24% of new TB cases and 62%
of those who have already been treated. The increasing num-ber of cases of DR-TB is accompanied by high rates of treat-ment failure and mortality and represents a major public health problem for the country and the region. The increase in the number of MDR-TB cases is due to poor treatment compliance, TB/HIV co-infection, lack of drugs, inappropri-ate treatment leading to acquired resistance and nosocomial TB transmission.
While the current MDR-TB treatment model in the Republic of Moldova is hospital-based, the Moldovan NTP has shown interest in exploring the outpatient MDR-TB case manage-ment model.
Health system challenge
As TB care relies heavily on hospitalization, it is very costly and increases the risk for nosocomial TB transmission; how-ever, there was no evidence for the effectiveness of the out-patient-based model of care.
Good practice in health system strengthening to improve prevention and care of M/XDR-TB
The revision of the model of care had to address the high costs of hospitalization, reduce nosocomial transmission and allow more patient-centred care. The aim of the study that accompanied the project was to collect evidence about the outpatient-based model of care and to evaluate the inno-vative MDR-TB management model combining rapid diag-nostics with outpatient MDR-TB treatment and intensified patient support between 2012 and 2014.
Initially, the new approach was met with considerable resist-ance by the staff and management of inpatient facilities and the public health service, which continued to insist on hos-pitalization and isolation of TB patients. Many outpatients had to be hospitalized because, under the rules of the man-datory health insurance, they could access drugs for adverse reactions only in hospitals; otherwise, outpatients had to
buy these drugs themselves. Alcohol consumption by TB patients was another challenge to the project, which had to be addressed by providing additional psychological support to patients with alcohol dependence.
To sensitize the stakeholders, including the public health service, round-table discussions were held, at which the pro-ject was introduced in the context of the need for change: to reduce costs, nosocomial transmission and stigma related to (DR-)TB.
Two regions with a high TB incidence and large numbers of MDR-TB patients (Orhei and Cahul) were selected for the project. Between January 2012 and December 2014, 107 MDR-TB cases were detected in Orhei and 63 in Cahul. A specific diagnostic algorithm comprising GeneXpert, smear microscopy, line probe assay, solid and liquid culture and a conventional DST (MGIT) were used to rapidly identify and manage MDR-TB patients. Of the 170 patients, 38 started outpatient treatment with a standardized MDR-TB regimen provided by the district TB clinic and primary health care facility, and 43 cases were managed as inpatients with the standard approach. Community TB centres currently funded by the Global Fund in 10 regions assisted the patients psy-chologically and legally and provided adherence support.
No major differences were found between inpatients and outpatients with regard to risk factors or clinical character-istics (new cases: 53.5% vs 68.4%; first- and second-line DR pattern: all MDR-TB with two XDR-TB cases among outpa-tients).
The median time to initiation of MDR-TB treatment after Xpert results was 10 days for inpatients and 6 days for out-patients. The proportions of sputum smear conversion (inpa-tients vs outpa(inpa-tients) was as follows: 38.7% vs 71.4% at 2 weeks, 96.7% vs 63.6% at 2 months and 86.7% vs 77.2% at 5 months. The median time to smear conversion was 28 vs 42 days; culture conversion was 59.0% vs 55.8% at month 1 and 94.7% vs 77.4 % at month 5, with a median time to culture conversion of 56 vs 56 days. The treatment outcomes were: