SA: Percentage [Source: DHIS]

Transcription

1 10 Tuberculosis Lieve Vanleeuw, Yoliswa Mzobe and Marian Loveday Introduction The End TB Strategy adopted by the World Health Assembly in 2014 aims to end the global TB epidemic with targets to reduce TB deaths by 95%, to reduce the number of new cases by 90% between 2015 and 2035, and to ensure that no family is burdened with catastrophic expenses due to TB. a A treatment success rate of 90% is one of the key operational indicators for countries to monitor their progress towards zero deaths, disease and suffering due to TB. In South Africa, the National Strategic Plan (NSP) for HIV, TB and STIs (NSP2017) has adopted this target to be reached by b In this chapter on TB, we refer to the targets of the End TB Strategy. However, the targets used are those of the National Department of Health s Annual Performance Plan (APP) 2016/ /19. c 10.1 TB symptom 5 years and older screened in facility rate As transmission is driving the TB epidemic in South Africa, the early detection of disease and getting those diagnosed with TB onto treatment as quickly as possible is of the utmost importance. It is for this reason that all clients entering PHC facilities are supposed to be screened for TB. This indicator measures the proportion of clients 5 years and older attending PHC facilities who were screened for TB. The numerator is the number of clients 5 years and older that were screened for TB and the denominator is the PHC headcount 5 years and older. Nationally the TB symptom 5 years and older screened in facility rate in 2016/17 was 51.6%. Figure 1: TB symptom 5 years and older screened in facility rate by province, 2016/17 NA SA: Percentage [Source: DHIS] a World Health Organization. End TB strategy. WHO/HTM/TB/ Geneva, Switzerland: World Health Organization, Available from [accessed 1 July 2017]. b SANAC. Let Our Actions Count. South Africa s National Strategic Plan for HIV, TB and STIs Pretoria: SANAC, za/2017/05/11/download-the-full-version-of-the-national-strategic-plan-for-hiv-tb-and-stis / [accessed 1 July 2017]. c South African National Department of Health. Annual Performance Plan 2016/ /2019. Pretoria. National Department of Health

2 Figure 2: TB symptom 5 years and older screened in facility rate by district, 2016/17 Central Karoo: DC5 Eden: DC4 Overberg: DC3 Cape Winelands: DC2 West Coast: DC1 Cape Town: CPT West Rand: DC48 Sedibeng: DC42 Xhariep: DC16 Ekurhuleni: EKU Ugu: DC21 umgungundlovu: DC22 Amajuba: DC25 Harry Gwala: DC43 ethekwini: ETH Zululand: DC26 Mopani: DC33 King Cetshwayo: DC28 uthukela: DC23 Amathole: DC12 Dr K Kaunda: DC40 umkhanyakude: DC27 Capricorn: DC35 umzinyathi: DC24 ilembe: DC29 Joe Gqabi: DC14 Vhembe: DC34 C Hani: DC13 Mangaung: MAN Johannesburg: JHB Tshwane: TSH Ehlanzeni: DC32 T Mofutsanyana: DC19 Pixley ka Seme: DC7 Fezile Dabi: DC20 Lejweleputswa: DC18 Bojanala: DC37 NM Molema: DC38 JT Gaetsewe: DC45 Waterberg: DC36 S Baartman: DC10 N Mandela Bay: NMA Nkangala: DC31 RS Mompati: DC39 A Nzo: DC44 Buffalo City: BUF G Sibande: DC30 Sekhukhune: DC47 OR Tambo: DC15 Frances Baard: DC9 Namakwa: DC6 ZF Mgcawu: DC8 NA NA NA NA NA NA SA: Percentage [Source: DHIS] 141

3 Map 1: TB symptom 5 years and older screened in facility rate by sub-district, 2016/17 Key findings and recommendations It is concerning that the Western Cape () did not report any data on this indicator and that some districts reported such low screening rates. Most of the districts in Northern Cape (), Eastern Cape () and North West () reported a screened rate below the national average. For South Africa, reducing TB transmission is a prerequisite for addressing the TB burden of the country. In the next financial year facilities have to ensure that many more clients 5 years and older attending PHC facilities are screened as an attempt to reach the 94% APP target. In the next financial year all facilities must implement and report screening for TB more rigorously TB client initiated on treatment rate This indicator measures the proportion of clients with a positive TB diagnosis who were started on treatment. The numerator is number of clients diagnosed with TB (using GeneXpert) who were started on treatment according to the Electronic TB Register. The denominator is the total number of clients who were diagnosed with TB using GeneXpert data reported by National Health Laboratory Service (NHLS). This indicator is sometimes referred to as the treatment gap or the initial loss to follow-up (ILTFU) rate. In 2016, the national average of clients diagnosed with TB and started on treatment was 72.8%. 142

4 Figure 3: TB client initiated on treatment rate by province, SA: Percentage [Source: ETR and NHLS Xpert] Key Findings A new concern for TB programmes globally is the initial loss to follow-up rate. This refers to patients who are diagnosed with TB, but not started on treatment. Initial loss to follow-up is an area that needs monitoring for both drug-sensitive and drug-resistant TB. The low proportion of clients diagnosed with TB who were started on treatment in four provinces is of concern: the Eastern Cape, KwaZulu-Natal (), Northern Cape and the North West. Most concerning is the North West where less than half the patients diagnosed with TB were started on treatment. South Africa will not reduce the TB burden if patients diagnosed with TB are not started on treatment. Four districts had rates that exceed 100% Xhariep (Free State ()), Capricorn (Limpopo ()), Waterberg () and Tshwane (Gauteng ()), and this needs to be investigated. 143

5 Figure 4: TB client initiated on treatment rate by district, 2016 Xhariep: DC16 Capricorn: DC35 Waterberg: DC36 Tshwane: TSH Vhembe: DC34 Ehlanzeni: DC32 Fezile Dabi: DC20 Cape Town: CPT Nkangala: DC31 Mangaung: MAN Lejweleputswa: DC18 Sekhukhune: DC47 West Coast: DC1 T Mofutsanyana: DC19 Cape Winelands: DC2 S Baartman: DC10 ZF Mgcawu: DC8 Mopani: DC33 Central Karoo: DC5 West Rand: DC48 G Sibande: DC30 N Mandela Bay: NMA Sedibeng: DC42 Eden: DC4 Johannesburg: JHB Ugu: DC21 umkhanyakude: DC27 Joe Gqabi: DC14 umgungundlovu: DC22 Overberg: DC3 umzinyathi: DC24 Namakwa: DC6 Zululand: DC26 Ekurhuleni: EKU C Hani: DC13 NM Molema: DC38 A Nzo: DC44 RS Mompati: DC39 Amathole: DC12 ethekwini: ETH Harry Gwala: DC43 Buffalo City: BUF King Cetshwayo: DC28 JT Gaetsewe: DC45 OR Tambo: DC15 Amajuba: DC25 Bojanala: DC37 ilembe: DC29 uthukela: DC23 Pixley ka Seme: DC7 Frances Baard: DC9 Dr K Kaunda: DC SA: Percentage [Source: ETR and NHLS Xpert] 144

6 10.3 TB/HIV co-infected client on ART rate This indicator measures the proportion of TB patients co-infected with HIV who were on antiretroviral therapy (ART) in The numerator is the total number of TB/HIV co-infected patients on ART and the denominator is the total number of TB/HIV co-infected patients. Antiretroviral therapy for co-infected TB/HIV patients is necessary to reduce mortality due to TB and achieve the End TB Strategy a and NSP targets. b As illustrated in Figure 5 below, the TB/HIV co-infected client on ART rate has increased significantly over the last 5 years, from 28.0% in 2011 to 88.0% in It is not clear why there was a decrease from 2015 to The target for the proportion of TB/HIV co-infected patients on ART in the APP is 80%. c This target is lower than the rate reported here as different data sources were used for setting the targets and programme monitoring. Figure 5: National TB/HIV co-infected client on ART rate, Percentage TB/HIV client initiate on ART rate 28.0% 60.6% 72.0% 85.8% 90.8% 88.3% Source: ETR. Figure 6: TB/HIV co-infected client on ART rate by province, SA: 88.3 Target: Percentage [Source: ETR] 145

7 Figure 7: TB/HIV co-infected client on ART rate by district, 2016 umgungundlovu: DC22 Joe Gqabi: DC14 OR Tambo: DC15 C Hani: DC13 West Rand: DC48 umzinyathi: DC24 A Nzo: DC44 King Cetshwayo: DC28 umkhanyakude: DC27 Frances Baard: DC9 Amathole: DC12 Buffalo City: BUF T Mofutsanyana: DC19 N Mandela Bay: NMA Ugu: DC21 Nkangala: DC31 Ehlanzeni: DC32 Mopani: DC33 ilembe: DC29 Xhariep: DC16 G Sibande: DC30 Sedibeng: DC42 S Baartman: DC10 Sekhukhune: DC47 Waterberg: DC36 Capricorn: DC35 NM Molema: DC38 Johannesburg: JHB Pixley ka Seme: DC7 Fezile Dabi: DC20 ZF Mgcawu: DC8 Dr K Kaunda: DC40 Tshwane: TSH JT Gaetsewe: DC45 uthukela: DC23 Harry Gwala: DC43 Mangaung: MAN Ekurhuleni: EKU Lejweleputswa: DC18 Zululand: DC26 Amajuba: DC25 Cape Town: CPT Vhembe: DC34 RS Mompati: DC39 Bojanala: DC37 ethekwini: ETH Namakwa: DC6 Eden: DC4 Cape Winelands: DC2 Central Karoo: DC5 West Coast: DC1 Overberg: DC SA: 88.3 Target: Percentage [Source: ETR] 146

8 Map 2: TB/HIV co-infected client on ART rate by sub-district, 2016 Key findings and recommendations Nationally the proportion of TB/HIV co-infected clients on ART in 2016 was 88.3%, above the national target of 80%. This increase is due to the change in ART policy whereby ART initiation in all TB/HIV co-infected clients irrespective of CD4 count is possible. Eight districts (15%) had an ART initiation rate below the 80% target, five of which were in the Western Cape. However, it is likely that the proportion of co-infected clients on ART in the Western Cape is much higher, as in the Western Cape this data is captured on a different database which is not reflected here. Given the risk of increased morbidity and mortality in TB/HIV co-infected clients, all co-infected clients should be started on ART as soon as possible, and all districts should aim for 90% or more of co-infected clients on ART rate in the 2017/18 financial year. 147

9 10.4 TB client treatment success rate TB treatment success rate measures the proportion of TB patients that completed treatment or were cured. The numerator for this indicator is the number of patients who completed treatment or were cured, the denominator is the sum of all TB patients in the cohort. Treatment success is used to measure the effectiveness of the TB programme. In the APP the target TB treatment success rate is 84% and in 2015 the national treatment success rate was 81.0%. c As can be seen in Figure 8, the national treatment success rate has increased, despite a dip in To date, with only one district attaining a treatment success of 90%, a sustained effort across the country will be needed to reach the 90% NSP 2017 target. b Figure 8: National TB treatment success rate, Percentage TB success all TB Source: ETR. Figure 9: TB client treatment success rate by province, SA: 81 Target: Percentage [Source: ETR] 148

10 Figure 10: TB client treatment success rate by district, 2015 Overberg: DC3 OR Tambo: DC15 umkhanyakude: DC27 umgungundlovu: DC22 umzinyathi: DC24 Johannesburg: JHB West Rand: DC48 Ekurhuleni: EKU Zululand: DC26 Nkangala: DC31 ilembe: DC29 C Hani: DC13 Tshwane: TSH Joe Gqabi: DC14 T Mofutsanyana: DC19 King Cetshwayo: DC28 A Nzo: DC44 Mopani: DC33 Mangaung: MAN Cape Town: CPT ethekwini: ETH Harry Gwala: DC43 Buffalo City: BUF Amathole: DC12 West Coast: DC1 Ugu: DC21 N Mandela Bay: NMA Ehlanzeni: DC32 G Sibande: DC30 Sedibeng: DC42 Pixley ka Seme: DC7 Vhembe: DC34 NM Molema: DC38 Lejweleputswa: DC18 Central Karoo: DC5 Eden: DC4 Amajuba: DC25 Fezile Dabi: DC20 S Baartman: DC10 Namakwa: DC6 uthukela: DC23 Sekhukhune: DC47 Waterberg: DC36 Cape Winelands: DC2 ZF Mgcawu: DC8 Xhariep: DC16 RS Mompati: DC39 Capricorn: DC35 Frances Baard: DC9 Bojanala: DC37 JT Gaetsewe: DC45 Dr K Kaunda: DC SA: 81 Target: Percentage [Source: ETR] 149

11 Figure 11: Trends in average district values by socio-economic quintile for TB treatment success rate, TB success all TB SEQ SEQ 1 (most deprived) SEQ 2 (deprived) SEQ 3 SEQ 4 (well off) 77.8 SEQ 5 (least deprived) Percentage Calendar Year Key findings and recommendations The national treatment success rate continues to improve. Eleven districts have attained the national target in 2015 with Overberg () achieving 90% treatment success, illustrating that it is feasible to attain the 2020 target of 90%. The treatment success rates in the North West () and Northern Cape have failed to improve adequately since All the districts in these provinces had treatment success rates below the national average. Furthermore, each province had two districts whose performance has declined from 2011 to In Bojanala and Dr K Kaunda () and Frances Baard and JT Gaetsewe (both ) treatment success declined from 2011 to In Limpopo four of the five districts had treatment success rates below the national average. have to focus on the poorly performing districts in their province to improve their overall treatment outcomes. In the last seven years the 20% (socio-economic quintile (SEQ1)) of the population that is the most deprived has made the most progress in treatment outcomes compared to the other four socio-economic quintiles. This is encouraging given the new focus on the very poor as a vulnerable group. If we are to reach the NSP target of 90% the provinces which have achieved a treatment success rate of over 80% should celebrate their good work, but at the same time ensure they build on their success and that further improvements are forthcoming. 150

12 10.5 TB client loss to follow-up rate The TB loss to follow-up rate measures the proportion of TB patients who interrupted treatment for two consecutive months or more (previously known as the defaulter rate). The numerator for this indicator is the number of TB clients lost to follow-up, the denominator is the number of TB clients who started treatment. To minimise the transmission of TB and the development of drug-resistant TB, it is important to minimise the loss to follow-up rate. The APP target for the loss to follow-up rate for TB is 5.4%. c As can be seen in the figure below, the national loss to followup rate has decreased over the last nine years and remained fairly constant over the past five years. Figure 12: National TB loss to follow-up rate, Percentage TB client loss to follow-up rate Source: ETR.Net Figure 13: TB client loss to follow-up rate by province, SA: 6.4 Target: Percentage [Source: ETR] 151

13 Figure 14: TB client loss to follow-up rate by district, 2015 umzinyathi: DC24 umkhanyakude: DC27 uthukela: DC23 Zululand: DC26 West Rand: DC48 Ugu: DC21 Mopani: DC33 OR Tambo: DC15 Overberg: DC3 Amathole: DC12 T Mofutsanyana: DC19 Joe Gqabi: DC14 King Cetshwayo: DC28 Harry Gwala: DC43 Ekurhuleni: EKU A Nzo: DC44 Fezile Dabi: DC20 umgungundlovu: DC22 RS Mompati: DC39 Xhariep: DC16 Pixley ka Seme: DC7 C Hani: DC13 Amajuba: DC25 NM Molema: DC38 Nkangala: DC31 G Sibande: DC30 Lejweleputswa: DC18 Namakwa: DC6 Ehlanzeni: DC32 Sekhukhune: DC47 Johannesburg: JHB Buffalo City: BUF Capricorn: DC35 Waterberg: DC36 ethekwini: ETH Tshwane: TSH Bojanala: DC37 Mangaung: MAN Dr K Kaunda: DC40 ilembe: DC29 Sedibeng: DC42 Frances Baard: DC9 Vhembe: DC34 N Mandela Bay: NMA ZF Mgcawu: DC8 Cape Town: CPT JT Gaetsewe: DC45 West Coast: DC1 S Baartman: DC10 Eden: DC4 Cape Winelands: DC2 Central Karoo: DC SA: 6.4 Target: Percentage [Source: ETR] 152

14 Figure 15: Treatment outcomes for TB patients by district, 2015 Prov District_code A Nzo: DC44 Amathole: DC12 Buffalo City: BUF C Hani: DC13 Joe Gqabi: DC14 N Mandela Bay: NMA OR Tambo: DC15 S Baartman: DC10 Fezile Dabi: DC20 Lejweleputswa: DC18 Mangaung: MAN T Mofutsanyana: DC19 Xhariep: DC16 Ekurhuleni: EKU Johannesburg: JHB Sedibeng: DC42 Tshwane: TSH West Rand: DC48 Amajuba: DC25 ethekwini: ETH Harry Gwala: DC43 ilembe: DC29 King Cetshwayo: DC28 Ugu: DC21 umgungundlovu: DC22 umkhanyakude: DC27 umzinyathi: DC24 uthukela: DC23 Zululand: DC26 Capricorn: DC35 Mopani: DC33 Sekhukhune: DC47 Vhembe: DC34 Waterberg: DC36 Ehlanzeni: DC32 G Sibande: DC30 Nkangala: DC31 Frances Baard: DC9 JT Gaetsewe: DC45 Namakwa: DC6 Pixley ka Seme: DC7 ZF Mgcawu: DC8 Bojanala: DC37 Dr K Kaunda: DC40 NM Molema: DC38 RS Mompati: DC39 Cape Town: CPT Cape Winelands: DC2 Central Karoo: DC5 Eden: DC4 Grand Total Overberg: DC3 West Coast: DC1 SYSGENOUTCOME (group) Treatment Success Transferred Out LTFU Died Failed Not Evaluated 3.1% 1.9% 2.0% 1.5% 3.6% 2.8% 2.4% 1.6% 1.8% 1.7% 5.8% 4.9% 4.4% 4.1% 3.8% 2.7% 1.6% 2.3% 4.1% 3.1% 4.3% 6.2% 7.3% 6.8% 5.5% 5.1% 4.6% 4.8% 3.2% 7.5% 6.6% 7.1% 9.3% 10.1% 9.0% 6.3% 9.5% 7.5% 5.6% 8.0% 11.8% 10.1% 7.2% 8.7% 9.1% 3.7% 4.7% 3.7% 5.5% 3.7% 8.1% 8.7% 6.7% 3.2% 8.4% 5.4% 12.3% 3.2% 15.4% 6.3% 3.0% 12.2% 14.7% 10.7% 7.4% 5.0% 14.5% 12.0% 7.5% 15.2% 7.1% 4.6% 14.5% 17.4% 9.4% 15.7% 3.5% 6.6% 6.7% 16.8% 1.9% 5.9% 6.7% 4.3% 4.1% 3.8% 6.6% 4.4% 5.7% 2.7% 6.0% 8.7% 9.6% 2.1% 10.4% 4.8% 6.4% 9.1% 7.0% 3.0% 2.1% 6.0% 3.5% 7.4% 3.2% 7.1% 4.0% 3.5% 1.6% TREATMENT (RX) START DATE 2.2% 10.9% 6.2% 8.9% 2.1% 4.6% 3.1% 8.0% 2.1% 15.4% 12.6% 6.4% 3.1% 6.3% 5.1% 6.2% 5.2% 1.9% 1.6% 1.6% 5.9% 3.5% 2.5% 2.8% 6.5% 6.0% 6.3% 4.5% 9.7% 2.9% 13.8% 2.7% 2.6% 4.9% 2.5% % 6.4% 6.3% 2.2% 1.5% 7.8% 2.1% 7.8% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 22% 24% 26% 28% 30% 32% 34% 36% 38% % of cases [axis truncated] 2.6% 7.0% 4.5% 9.3% 1.4% 2.3% 1.8% 1.5% 5.2% 1.6% 5.1% 2.3% 2.5% 11.8% 5.2% 2.9% 2.6% 7.5% 7.7% 6.8% 1.6% 10.4% 4.8% 7.3% 2.7% 81.9% 81.2% 81.2% 83.9% 83.3% 80.6% 88.5% 77.2% 77.4% 78.8% 81.9% 83.0% 72.8% 85.3% 86.4% 79.9% 83.6% 86.2% 77.6% 81.6% 81.6% 84.0% 82.9% 80.8% 87.1% 88.2% 87.0% 75.0% 85.1% 70.3% 81.9% 75.0% 79.7% 74.4% 80.3% 80.2% 84.9% 68.0% 64.0% 76.7% 79.9% 73.5% 64.7% 78.8% 71.1% 81.8% 74.4% 78.2% 77.9% 90.9% 81.0% 81.0% Note: X-axis is truncated to show the range of treatment outcomes. 153

15 Figure 16: Trends in average district values by socio-economic quintile for TB loss to follow-up rate, TB client LTF rate SEQ SEQ 1 (most deprived) SEQ 2 (deprived) 9 SEQ SEQ 4 (well off) SEQ 5 (least deprived) Percentage Calendar Year Key findings and recommendations Loss to follow-up was highest in SEQ5, 20% of the population that is the least deprived, and the lowest in SEQ1, 20% of the population that is the most deprived. Although the national trend for the loss to follow-up rate is decreasing, only KwaZulu-Natal achieved the national target of 5.4% in Four districts in KwaZulu-Natal had a loss to follow-up rate less than 3%. The three Western Cape districts with loss to follow-up rates higher than 12.5% (Eden, Cape Winelands and Central Karoo) need to address their loss to follow-up rates. More flexible service hours, compassionate health care workers and improved patient education have been reported to improve adherence to TB treatment. d 10.6 TB death rate The TB death rate measures the proportion of TB patients that died whilst on treatment. The numerator is the number of TB patients that died; the denominator is the total number of TB patients in the cohort. As TB remains the country s leading cause of death, e one of the goals of the 2017 NSP is to reduce the deaths associated with TB. This is in line with the End TB strategy which aims to reduce the number of TB deaths by 35% by 2020, 75% by 2025, and 95% by 2035, compared with b The APP target for death rate in TB patients is 5% and in 2015, 6.6% of TB patients were reported to have died during TB treatment. c d Munro, S A, et al. (2007). Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Med, 4 (7): e238. e Statistics South Africa. Mortality and causes of death in South Africa, 2014: Findings from death notification. Pretoria. Statistics South Africa

16 Figure 17: TB death rate by province, SA: 6.6 Target: Percentage [Source: ETR] Map 3: TB death rate by district,

17 Figure 18: TB death rate by district, 2015 Overberg: DC3 Cape Winelands: DC2 ethekwini: ETH Cape Town: CPT Central Karoo: DC5 ilembe: DC29 OR Tambo: DC15 West Coast: DC1 Johannesburg: JHB umkhanyakude: DC27 Eden: DC4 umgungundlovu: DC22 King Cetshwayo: DC28 Ugu: DC21 Ekurhuleni: EKU N Mandela Bay: NMA uthukela: DC23 Nkangala: DC31 Namakwa: DC6 Buffalo City: BUF West Rand: DC48 JT Gaetsewe: DC45 C Hani: DC13 ZF Mgcawu: DC8 Amathole: DC12 Zululand: DC26 Tshwane: TSH Harry Gwala: DC43 Ehlanzeni: DC32 Bojanala: DC37 Frances Baard: DC9 S Baartman: DC10 Vhembe: DC34 Lejweleputswa: DC18 A Nzo: DC44 G Sibande: DC30 NM Molema: DC38 Xhariep: DC16 Joe Gqabi: DC14 Mangaung: MAN Pixley ka Seme: DC7 Sedibeng: DC42 RS Mompati: DC39 umzinyathi: DC24 Mopani: DC33 Dr K Kaunda: DC40 T Mofutsanyana: DC19 Waterberg: DC36 Amajuba: DC25 Capricorn: DC35 Sekhukhune: DC47 Fezile Dabi: DC SA: 6.6 Target: Percentage [Source: ETR] 156

18 Figure 19: National trend for unsuccessful treatment outcomes, % 9% Died SYSGENOUTCOME (group) LTFU Died Failed Not Evaluated 8% LTFU 7% 6% TO 5% Not Evaluated 4% 3% 2% Failed 1% 0% 2008 Q Q Q Q Q Q Q Q3 Quarter of TREATMENT (RX) START DATE Source: ETR. Key findings and recommendations The death rate during TB treatment varies significantly across the provinces and districts of the country. In the Western Cape five of the nine districts attained the national target in However, although the Western Cape was the only province to achieve the national target, we suspect that the high loss to follow-up rates in five Western Cape districts may be concealing a number of patients who have died. The death rate in Limpopo and the Free State was at least twice that of the Western Cape. Four of the nine districts reporting a death rate above 10% were in Limpopo. The districts with death rates higher than 10%, together with Fezile Dabi () which reported a death rate of 15.4%, need to investigate which TB patients are dying and why and then develop targeted interventions to address these issues. This fluctuation in death rate could be due to poor TB programme performance or inadequate TB/HIV service integration. 157

19 10.7 TB rifampicin resistance confirmed client rate This indicator measures the proportion of TB suspects detected to have rifampicin resistance. The numerator is the number of TB tests (detected using GeneXpert) that showed rifampicin resistance. The denominator is the total number of TB tests that indicated the presence of Mycobacterium Tuberculosis. Globally in 2014, there were an estimated 3.3% of new cases and 20% of previously treated cases with drug-resistant TB (DR-TB). f In South Africa, it is estimated that 3.5% of new cases and 7.1% of previously treated TB cases have DR-TB. f The confirmed rifampicin resistant client rate has been relatively stable in the last four years. In 2016, the national average was 6.2% (Figure 20). Figure 20: TB rifampicin resistance confirmed client rate by province, SA: Percentage [Source: NHLS Xpert] f World Health Organization. Global tuberculosis report WHO/HTM/TB/ Geneva, Switzerland: World Health Organization, 2016 (

20 Figure 21: TB rifampicin resistance confirmed client rate by district, 2016 ` NM Molema: DC38 Eden: DC4 Cape Winelands: DC2 Namakwa: DC6 Central Karoo: DC5 Waterberg: DC36 Sekhukhune: DC47 JT Gaetsewe: DC45 Xhariep: DC16 Overberg: DC3 Mangaung: MAN Lejweleputswa: DC18 RS Mompati: DC39 A Nzo: DC44 Joe Gqabi: DC14 Sedibeng: DC42 West Coast: DC1 Mopani: DC33 Frances Baard: DC9 Johannesburg: JHB OR Tambo: DC15 West Rand: DC48 C Hani: DC13 T Mofutsanyana: DC19 Bojanala: DC37 Pixley ka Seme: DC7 Cape Town: CPT S Baartman: DC10 Ugu: DC21 Ekurhuleni: EKU Capricorn: DC35 Dr K Kaunda: DC40 Fezile Dabi: DC20 Amathole: DC12 Nkangala: DC31 Tshwane: TSH Vhembe: DC34 umgungundlovu: DC22 ZF Mgcawu: DC8 Harry Gwala: DC43 ethekwini: ETH N Mandela Bay: NMA umzinyathi: DC24 uthukela: DC23 Buffalo City: BUF Amajuba: DC25 ilembe: DC29 G Sibande: DC30 Ehlanzeni: DC32 Zululand: DC26 umkhanyakude: DC27 King Cetshwayo: DC SA: Percentage [Source: NHLS Xpert] 159

21 Key findings and recommendations In 2016, Mpumalanga () and KwaZulu-Natal had the highest proportion of clients suspected to have TB detected with rifampicin resistance (RR). The Western Cape had the lowest. Three districts in KwaZulu-Natal, King Cetshwayo, umkhanyakude and Zululand had RR-TB rates above 10%. In Mpumalanga there were two districts (Ehlanzeni and Gert Sibande) with rates higher than 8%. These two provinces need to investigate reasons for this and implement strategies to reduce transmission by reducing the time from diagnosis to treatment initiation and improving adherence. Two recent South African studies show that transmission rather than acquired resistance is driving the DR-TB epidemic in South Africa. To address the burden of DR-TB in South Africa considerable effort needs to be made to screen all patients at PHC facilities for TB, diagnose active disease and start appropriate treatment as quickly as possible. g,h 10.8 TB rifampicin resistant confirmed treatment start rate This indicator measures the proportion of diagnosed rifampicin resistant TB patients that have started treatment. The numerator for this indicator is the number of TB rifampicin resistant confirmed clients that have started treatment (from the Electronic Drug-resistant Tuberculosis Register (EDRWeb), while the denominator is the total number of TB rifampicin resistant confirmed clients (NHLS GeneXpert). Historically there has been a wide gap between the number of patients that are diagnosed and those started on treatment. Until 2014, less than 50% of diagnosed rifampicin resistant patients were started on treatment (Figure 22). Closing this gap will depend on improving accessibility to DR-TB services through decentralising treatment. Figure 22: Proportion of rifampicin resistant patients started on treatment, Percentage Proportion of rifampicin resistant patients started on treatment Sources: : A policy framework on decentralised and deinstitutionalised management for SA. i : WHO Global TB reports. j 2016: Calculated from NHLS GeneXpert data and EDRWeb. g Shah S, Auld S, Brust J, Mathema B, Ismail N, Moodley P, Mlisana K, Allana S, Campbell A, Mthiyane T, Morris N, Mpangase P, van der Meulen H, Omar S, Brown T, Narechania A, Shaskina E, Kapwata T, Kreiswirth B, Gandhi N. (2017). Transmission of Extensively Drug-Resistant Tuberculosis in South Africa. New England Journal of Medicine. 376: h Dheda K, Limberis JD, Pietersen E, Phelan J, Esmail A, Lesosky M, Fennelly KP, teriele J, Mastrapa B, Streicher EM. Outcomes, infectiousness, and transmission dynamics of patients with extensively drug-resistant tuberculosis and home-discharged patients with programmatically incurable tuberculosis: a prospective cohort study. The Lancet Respiratory Medicine Apr;5(4): doi: /S (16) Epub 2017 Jan 19. [Accessed 1 July 2017]. i South African Department of Health. Multi-drug resistant tuberculosis: A policy framework on decentralised and deinstitutionalised management for South Africa. Pretoria. South Africa. Department of Health. South Africa. National Department of Health South Africa j World Health Organization. Global Tuberculosis Report Geneva. World Health Organization. 160

22 Figure 23: TB rifampicin resistant clients treatment initiation rate by province, SA: 68 Target: Percentage [Source: EDRWeb, NHLS Xpert] 161

23 Figure 24: TB rifampicin resistant clients treatment initiation rate by district, 2016 Dr K Kaunda: DC40 Namakwa: DC6 Buffalo City: BUF Nkangala: DC31 Frances Baard: DC9 Central Karoo: DC5 uthukela: DC23 umzinyathi: DC24 Lejweleputswa: DC18 umkhanyakude: DC27 Ugu: DC21 ZF Mgcawu: DC8 Pixley ka Seme: DC7 ethekwini: ETH T Mofutsanyana: DC19 Eden: DC4 Waterberg: DC36 Cape Town: CPT G Sibande: DC30 Mangaung: MAN umgungundlovu: DC22 RS Mompati: DC39 Xhariep: DC16 Fezile Dabi: DC20 S Baartman: DC10 Zululand: DC26 Ekurhuleni: EKU ilembe: DC29 King Cetshwayo: DC28 Harry Gwala: DC43 A Nzo: DC44 Capricorn: DC35 Cape Winelands: DC2 Mopani: DC33 N Mandela Bay: NMA NM Molema: DC38 Ehlanzeni: DC32 Johannesburg: JHB Joe Gqabi: DC14 Overberg: DC3 Amajuba: DC25 Sekhukhune: DC47 C Hani: DC13 Sedibeng: DC42 Vhembe: DC34 Amathole: DC12 West Rand: DC48 Bojanala: DC37 OR Tambo: DC15 Tshwane: TSH West Coast: DC1 JT Gaetsewe: DC SA: 68 Target: Percentage [Source: EDRWeb, NHLS Xpert] 162

24 Key findings and recommendations For this indicator, different data sources had to be used for the numerator (EDRWeb) and the denominator (NHLS database) which together with poor data quality probably accounts for the invalid results in some districts. This is the case in Namakwa () and Dr K Kaunda () where the treatment initiation rates are above 100%. It is concerning that in seven districts treatment initiation rates remain below 50%. In part, this might be because treatment may have been initiated in a different district from where the diagnostic test was conducted. While the gap between the number of patients diagnosed and those started on treatment is slowly closing, one in three confirmed DR-TB patients is still not started on treatment and will continue to transmit DR-TB. All facilities need to ensure that patients diagnosed with rifampicin resistance are started on treatment as quickly as possible. Data verification and cleaning should be a priority for all districts to improve the quality of their DR-TB data Drug-resistant TB treatment success rate The DR-TB treatment success rate measures the proportion of DR-TB patients that completed treatment or were cured. The numerator for this indicator is the number of patients who were cured or completed treatment; the denominator is all DR-TB patients in the cohort. As all treatment for DR-TB at this time was two years, treatment outcomes for DR-TB lag by two years compared to the one year lag for drug-sensitive TB. The APP target for DR-TB treatment success rate is 55%, and in 2014, the national treatment success rate reported was 50.5%. c The National Department of Health (NDoH) has however set a very ambitious target of 75% in the NSP. b To reach this target, the NDoH has taken a number of bold steps to address the DR-TB burden in South Africa, including the introduction of new and repurposed drugs and a shortened DR-TB regimen. The hope is that these initiatives will make it possible to improve treatment success rates for DR-TB and reach the NSP 2020 treatment success target. Figure 25: Drug-resistant TB treatment success rate by province, SA: 50.5 Target: Percentage [Source: EDRWeb (Electronic Drug Resistant Tuberculosis Register)] 163

25 Figure 26: Drug-resistant TB client treatment success rate by district, 2014 NM Molema: DC38 Bojanala: DC37 Frances Baard: DC9 JT Gaetsewe: DC45 Nkangala: DC31 umkhanyakude: DC27 RS Mompati: DC39 Vhembe: DC34 Tshwane: TSH umzinyathi: DC24 Capricorn: DC35 Mopani: DC33 King Cetshwayo: DC28 Sekhukhune: DC47 A Nzo: DC44 Ugu: DC21 uthukela: DC23 Zululand: DC26 Amajuba: DC25 Johannesburg: JHB umgungundlovu: DC22 ethekwini: ETH Dr K Kaunda: DC40 ilembe: DC29 T Mofutsanyana: DC19 Harry Gwala: DC43 Central Karoo: DC5 Ehlanzeni: DC32 Xhariep: DC16 Cape Winelands: DC2 West Coast: DC1 Amathole: DC12 Fezile Dabi: DC20 Sedibeng: DC42 G Sibande: DC30 Ekurhuleni: EKU S Baartman: DC10 Waterberg: DC36 West Rand: DC48 Lejweleputswa: DC18 Joe Gqabi: DC14 OR Tambo: DC15 N Mandela Bay: NMA Buffalo City: BUF Cape Town: CPT Pixley ka Seme: DC7 ZF Mgcawu: DC8 Mangaung: MAN C Hani: DC13 Eden: DC4 Namakwa: DC6 Overberg: DC3 NA NA NA NA NA SA: 50.5 Target: Percentage [Source: EDRWeb (Electronic Drug Resistant Tuberculosis Register)] 164

26 Key findings and recommendations The roll-out of new and repurposed drugs must be accompanied by extensive training and the adaptation and strengthening of the recording and reporting system to ensure better outcomes. However, ongoing training and supportive supervision will have to continue as the DR-TB programme is complex and regimens will undoubtedly be modified. Careful monitoring of the roll-out of new and repurposed drugs and the short DR-TB regimen is recommended to ensure DR-TB services are equitably distributed and equally effective across rural and urban areas. Seventeen districts reported treatment success rates below 50% in In contrast, umkhanyakude s () treatment success rate of 71% illustrates that effective DR-TB services can be delivered in rural, resource-limited districts. The failure of certain districts to report treatment outcomes for DR-TB patients is concerning Drug-resistant TB client loss to follow-up rate The DR-TB loss to follow-up rate measures the proportion of DR-TB patients that interrupted treatment for two consecutive months or more. The numerator for this indicator is the number of DR-TB patients who interrupted treatment for two consecutive months or more and the denominator is the total number of DR-TB patients in the cohort. The national average loss to follow-up rate for DR-TB patients in 2014 was 17.9%, which is higher than the APP target of 16%. c It is hoped that with the introduction of new drugs and the short regimen, patients will find the treatment more tolerable and loss to follow-up rates will drop. k The variation in loss to follow-up rates across the provinces may be a reflection of data quality. Figure 27: Drug-resistant TB client loss to follow-up rate by province, SA: 17.9 Target: Percentage [Source: EDRWeb (Electronic Drug Resistant Tuberculosis Register)] k Lessem E, Cox H, Daniels C, et al. (2014). Access to new medications for the treatment of drug-resistant tuberculosis: Patient, provider and community perspectives. Int J Infect Dis, 32:

27 Map 4: Drug-resistant TB client loss to follow-up rate by district,

28 Figure 28: Drug-resistant TB client loss to follow-up rate by district, 2014 umkhanyakude: DC27 umzinyathi: DC24 S Baartman: DC10 RS Mompati: DC39 N Mandela Bay: NMA Nkangala: DC31 A Nzo: DC44 Zululand: DC26 Dr K Kaunda: DC40 Mopani: DC33 G Sibande: DC30 Buffalo City: BUF Johannesburg: JHB umgungundlovu: DC22 Pixley ka Seme: DC7 Amathole: DC12 Harry Gwala: DC43 JT Gaetsewe: DC45 Tshwane: TSH T Mofutsanyana: DC19 Sekhukhune: DC47 OR Tambo: DC15 Ugu: DC21 Ehlanzeni: DC32 Sedibeng: DC42 Joe Gqabi: DC14 West Rand: DC48 Vhembe: DC34 Amajuba: DC25 uthukela: DC23 King Cetshwayo: DC28 Capricorn: DC35 Frances Baard: DC9 C Hani: DC13 Mangaung: MAN Fezile Dabi: DC20 ethekwini: ETH ilembe: DC29 Ekurhuleni: EKU Waterberg: DC36 ZF Mgcawu: DC8 Central Karoo: DC5 West Coast: DC1 Cape Winelands: DC2 Xhariep: DC16 Lejweleputswa: DC18 Eden: DC4 Namakwa: DC6 Cape Town: CPT Overberg: DC3 Bojanala: DC37 NM Molema: DC NA NA SA: 17.9 Target: Percentage [Source: EDRWeb (Electronic Drug Resistant Tuberculosis Register)] 167

29 Key findings and recommendations The loss to follow up rates remained high, with 50% of districts failing to achieve the target of 16%. Reasons for this poor performance need to be investigated and appropriate retention in care strategies implemented. In 2014 umkhanyakude and umzinyathi (both ) districts reported the lowest loss to follow up rates, 6.7% and 6.8% respectively. Lessons from these districts can be scaled up in other districts with similar challenges. As South Africa will be treating large numbers of patients with the new and repurposed drugs, facilities need to ensure that patients stay on treatment and do not develop drug resistance to the few new drugs now available. To improve adherence to treatment patient education about DR-TB disease and the treatment must be improved. Furthermore, community-based support services, such as the Ward Based Outreach teams, must be mobilised to support patients with DR-TB and utilised to contact patients who do not return to the services for their monthly follow-up appointments Drug-resistant TB client death rate The DR-TB death rate measures the proportion of DR-TB patients that died while on treatment. The numerator is the number of DR-TB patients that died, the denominator is the total number of DR-TB patients in the cohort. In South Africa, the average death rate for DR-TB patients in 2014 was 23%, which is higher than the APP target c of 12%. Figure 29: Drug-resistant TB client death rate by province, Target: 12 SA: Percentage [Source: EDRWeb (Electronic Drug Resistant Tuberculosis Register)] 168

30 Figure 30: Drug-resistant TB client death rate by district, 2014 Central Karoo: DC5 Waterberg: DC36 West Coast: DC1 Tshwane: TSH King Cetshwayo: DC28 Vhembe: DC34 Capricorn: DC35 Cape Winelands: DC2 ilembe: DC29 ethekwini: ETH umkhanyakude: DC27 Xhariep: DC16 Cape Town: CPT T Mofutsanyana: DC19 Ekurhuleni: EKU Ugu: DC21 Johannesburg: JHB uthukela: DC23 Mopani: DC33 Sekhukhune: DC47 Amajuba: DC25 Sedibeng: DC42 Fezile Dabi: DC20 Nkangala: DC31 umzinyathi: DC24 umgungundlovu: DC22 Eden: DC4 Lejweleputswa: DC18 Zululand: DC26 RS Mompati: DC39 Namakwa: DC6 OR Tambo: DC15 Dr K Kaunda: DC40 Ehlanzeni: DC32 Amathole: DC12 Harry Gwala: DC43 A Nzo: DC44 G Sibande: DC30 Frances Baard: DC9 C Hani: DC13 Overberg: DC3 ZF Mgcawu: DC8 West Rand: DC48 S Baartman: DC10 Mangaung: MAN Joe Gqabi: DC14 N Mandela Bay: NMA Buffalo City: BUF Pixley ka Seme: DC7 Bojanala: DC37 JT Gaetsewe: DC45 NM Molema: DC NA Target: 12 SA: Percentage [Source: EDRWeb (Electronic Drug Resistant Tuberculosis Register)] 169

31 Key findings and recommendations None of the provinces attained the target of 12% in The national average for the death rate of DR-TB patients was 23% with six provinces reporting death rates above 20%. Across the provinces death rates varied considerably. In the Eastern Cape and Northern Cape, close to one in three DR-TB patients died whilst on treatment in Death rates varied across the districts too. Three Eastern Cape districts (Joe Gqabi, Nelson Mandela Bay and Buffalo City), two Northern Cape districts (JT Gaetsewe, and Pixley Ka Seme) and one district in North West (Bojanala) reported death rates greater than 35%. Moreover, two districts, JT Gaetsewe () and Bojanala () reported death rates of 57.1% and 50.0% respectively, which are exceptionally high and require further investigation. All provinces should investigate the causes of the high death rates and develop targeted interventions to address the problems identified. 170