DURBAN, 4 July 2008 (IRIN) - TB cure rates in South Africa have remained stubbornly low – about 60 percent nationally, but less than 50 percent in many districts. A number of studies presented at the national TB conference in Durban this week looked at some of the reasons why South Africa's programme is failing.

Directly Observed Treatment Short-course (DOTS), in which community health workers, known as DOTS supporters, literally watch tuberculosis (TB) patients swallow their daily medication, has been promoted by the World Health Organisation (WHO) as the gold standard for TB treatment and forms the cornerstone of South Africa's TB programme.

Yet in many districts DOTS simply is not being implemented. In four districts of KwaZulu-Natal Province, described as TB "crisis" districts in a province with the highest TB burden in the country, a Medical Research Council (MRC) study found that only 43 out of 70 health facilities had a DOTS programme.

The MRC noted that districts with better DOTS coverage had better cure rates, but could not say whether the DOTS supporters or other factors had made the difference.  

Local health authorities often argue that they lack the financial or human resources to implement effective TB programmes, but Dr Joven Jebio Ongole, from Piet Retief Hospital in eastern Mpumalanga Province, described how few staff and limited resources, if they were well managed, could radically improve a previously dysfunctional district TB programme.

Ongole and his colleagues scraped together staff, equipment and furniture to set up a TB unit that supported the work of primary health-care clinics. The TB team at the hospital improved laboratory turnaround times, reached over 90 percent of patients with the DOTS system, and reduced the loss-to-follow-up rate to less than one percent. "Good coordination and teamwork is the key," said Ongole.

In-depth interviews by the University of KwaZulu-Natal's Department of Public Health with a small number of TB patients found that basic knowledge of the importance of completing their six-month course of medication, how TB is transmitted and the links between TB and HIV was often lacking, despite regular contact with their DOTS supporters. "I feel cured," said one respondent. "What is the point of continuing with medication?"

Although some patients found their DOTS supporter helpful, others worried about being seen visiting them every day because of the stigma associated with TB. Poverty and lack of food, or the need to work to support family members, were other factors that negatively affected adherence to treatment.

Myra Taylor, a researcher at the University of KwaZulu-Natal, pointed out that simply educating and counselling TB patients about their disease and the importance of completing treatment and testing for HIV could improve cure rates.

Several delegates wondered why TB programmes did not help patients take responsibility for their health in the same way that HIV/AIDS programmes did. "We're passing responsibility to treatment supporters and 'buddies'," said one delegate.

"Not much has been done for TB patients in terms of counselling and support," Sbongile Ntshanga of the MRC told IRIN/PlusNews. "A patient goes through classes before starting ART [antiretroviral treatment], but we don't do the same for TB treatment.' 

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