Why Shorter tuberculosis (TB) Regimen is the Most Preferred by Patients in Eswatini

Siphephelosethu Ntjangase is a 21-year-old university student from Hluti village in the Shiselweni region who suffers from pulmonary drug resistant tuberculosis (DR-TB).  In October 2021 before getting checked, he noticed that he was losing weight, sweating at night and had a persistent cough that had lasted over a year. From the first test, the diagnosis was not conclusive which forced him to opt for a second opinion and that is when he tested positive for tuberculosis (TB). Siphephelosethu was immediately sent into isolation at Pigg’s Peak Government Hospital to avoid infecting other people and thereafter referred to Nhlangano Health Center for treatment. Nhlangano Health Centre is the national designated TB treatment centre.

“ I was scared at first because I am not sickly and taking daily medication was not good at all for me. I told the people who had been near me to get tested and luckily enough no one tested positive for TB”

Siphephelosethu had been taking his medicine religiously until the civil unrest experienced in the country in 2021 resulted in him stopping treatment for a while since he could not access the hospital.

“At least when I started taking treatment, the effects were not as bad as I had imagined when I got diagnosed. I started gaining weight and feeling like myself again with dizziness and nausea being my only side effects. The nurse gave me tablets to take thirty minutes before taking the drug and this has really helped me”

Previously Multi Drug Resistant TB (MDR-TB) treatment  required a course of second-line drugs which included injectables for at least 24  months and up to 36  months, supported by counselling and monitoring for adverse events. Even though these regimens were effective, some patients experienced severe side effects including hearing loss, kidney, and liver injury mainly due to injectables. The longer duration of treatment also contributed to high lost to follow up. The World Health Organization then recommended countries to forgo the non-injectable regimens, adopt all oral MDRTB treatment, shorter regimens and look at innovative approaches which included adherence enablers to support patients.

‘Initially, I thought I would die but I am happy I never experienced any stigma from either my family or the community. My aunt even attended a family treatment support workshop where she was educated about TB and thereafter enlightened other family members. The nurses also came to my home for the same” said Siphephelosethu.

Dr Takudzwanashe Gwitima from Médecins Sans Frontières (MSF) says the shorter regimen that Siphephelosethu is on is a preferred option by most patients who only use it for between nine to twelve months and has less side effects.

“Initially, patients would come for daily injections for eight months plus tablets and tablets all through for the rest of the year(s). They would experience severe side effects like loss of hearing which in some instances would lead to deafness, kidney issues and a lot of pain from the daily injections. It used to be so traumatizing for me injecting children daily and seeing them cry was not a good feeling. At least now the mother can crush the medicine and give the baby to take”- Dr Gwitima

In Eswatini, most patients are adhering to the oral short course therapy (OSCT) since they are tolerable with less side effects . This is evident as the treatment MDR-TB success rate improved from 74 % in 2018 to 79 % in 2021.  A figure that is higher than the global treatment success  rate of 59% according to the Global TB report 2021. The lost to follow up improved from 6% to less than 2% and even in the context of COVID-19 adherence seemed to be improving. Additionally, given the  long duration of MDRTB treatment as well as safety precautions that TB patients must take including isolating (which often include loss of income) , the WHO recommended for them to be given food baskets to cushion them from socio-economic shocks.

Multi Drug Resistant TB is of concern in Eswatini, it accounts for about 10% of diagnosed cases. Multi Drug resistant TB (DR-TB) is more difficult to treat than the drug-susceptible ones. In 2020 the new WHO DR-TB guidelines were published with Eswatini quickly adopting the guidance and reviewing the DR-TB guidelines in 2019 which recommended use of all oral regimens. The same year (2019) Eswatini with support from MSF developed a protocol for implementation of shorter all oral regimen in 2020.

Unfortunately, due to the COVID 19 pandemic, the implementation was delayed by a year. Shorter all oral regimen was later implemented in two out of the four regions under operational research. After 3 months of implementation, there was an assessment by the WHO Regional Green Light Committee consultants, and they recommended the scale up to the whole country and this was done in two months with support from President’s Emergency Plan for AIDS Relief (PEPFAR) partners.

Moving forward the country will continue to scale up use of all oral short regimens and will be training nurses to initiate these treatments to be accessible in more health facilities to further improve patient outcomes and impact. These are efforts to ensure Universal health Coverage, leaving no one behind.Distributed by APO Group on behalf of World Health Organization (WHO) – Eswatini.

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