Improved TB Treatment Outcomes at Facilities Enhanced by a Non-governmental Organization-assisted ART Program: Western Cape, South Africa
G Fatti, Ashraf Grimwood*, and P Bock
Absolute Return for Kids, Cape Town, South Africa
Background: The Western Cape, South Africa has one of the highest burdens of tuberculosis (TB) in the world, with 70% of
TB patients co-infected with HIV. ART improves TB treatment outcomes. Absolute
Return for Kids (ARK) is a non-governmental organization (NGO) that assists the
Department of Health (DOH) in increasing access to ART, primarily by providing clinical
and adherence support staff for the ART program. This study aimed to compare TB
treatment outcomes between sites in the Western Cape that had ART services enhanced
by ARK, and sites that were not enhanced by ARK or had no ART service.
Methods: A retrospective analysis of routine DOH
data from 2004 to 2007 was performed, including multivariable
maximum-likelihood logit estimates for grouped data. Outcomes for the periods
before and after ARK entry to sites were also compared.
Results: At 98 non-ART-enhanced sites, 32,853 cases
of smear-positive pulmonary TB were treated, of whom 23,232 (70.7%; CI 70.2 to 71.2)
were cured. At 11 ART-enhanced sites, 2822 cases were treated, of whom 2222
(78.7%; CI 77.2 to 80.2) were cured, amounting to a relative increase of 11.3%
(CI 9.1 to 13.6; p <0.0001). At non-ART-enhanced sites, 3685 patients
(11.2%; CI 10.9 to 11.6) defaulted treatment, while 181 (6.4%; CI 5.5 to 7.4; p
<0.0001) defaulted at ART-enhanced sites, i.e. a relative decrease of
42.8% (CI 33.9 to 50.5). An additional 6-month period of ARK being present at a
site per calendar year was associated with a 23% lower risk of treatment
failure (OR 0.77; CI 0.73 to 0.81; p <0.0001) from 2004 to 2007, with
a 44% reduced risk (OR 0.56; CI 0.50 to 0.64; p <0.0001) in 2004. Similarly,
the risk of defaulting treatment was reduced by 31% (OR 0.69; CI 0.64 to 0.76; p
<0.0001) from 2004 to 2007, with a 52% (OR 0.48; CI 0.38 to 0.62; p <0.0001)
reduced risk in 2004. Prior to ART enhancement, 60.8% (CI 59.2 to 62.5) of
patients were cured, while 74.0% (CI 71.6 to 76.3) were cured following ART enhancement,
amounting to a relative increase of 21.6 % (CI 16.7 to 26.7; p <0.0001).
Prior to ART enhancement, 13.6% (CI 12.4 to 14.9) patients defaulted treatment,
and 9.5% (CI 8.0 to 11.2) defaulted following ART enhancement, i.e. a relative
decrease of 30.0% (CI 15.9 to 41.8; p <0.0001).
Conclusions: ART sites enhanced by ARK had better TB
treatment outcomes than non-ART-enhanced sites, treatment outcomes improved following
ART enhancement, and the risks of poor outcome were lower for increased
duration of ART enhancement. TB treatment outcomes are significantly improved
with the scale-up of adherence-supported ART services.