From the Ground Up: Building a Drug-Resistant TB Program in Uganda

Uganda is one of the world's 22 high burden countries for tuberculosis (TB). Despite having a national treatment program for drug-sensitive TB, there has been an emergence of drug-resistant strains of the disease, which are presenting a new and urgent threat to people's health. So far in Uganda, 226 cases of multidrug-resistant tuberculosis (MDR-TB) have been confirmed, spread across 40 districts, but the true figure is likely to be much higher.

Improvements in diagnostics in Uganda mean that drug-resistant tuberculosis (DR-TB) can now be diagnosed—but it can't yet be treated. As yet, there are no second-line TB drugs in the country. Until the government is able to offer treatment and care, people with drug-resistant TB will be left in limbo. Unless they can afford to leave the country and pay for treatment elsewhere, the most they can hope for is that the drugs become available in Uganda before their condition proves fatal. There is no data available for how many have already died.

The best way to stop the disease from spreading is to start patients on treatment early. Aware of the urgency of the problem, the Ugandan government is taking steps to start treating DR-TB. Funding for DR-TB drugs is on its way, the drug order has been placed, and the government is planning a 40-bed ward for DR-TB patients in Mulago hospital in Kampala.

However, MSF's experience of treating DR-TB in Uganda strongly suggests that centralized care is not the answer. Many patients and their caregivers from rural districts will find it impossible to manage a lengthy stay in the capital, and default rates are likely to skyrocket.

MSF firmly believes that a feasible model of care already exists in the Ugandan context. Since 2009, MSF has been running a community-based and comprehensive TB treatment program in Kitgum, in northern Uganda, hand in hand with the Ministry of Health.

The preliminary treatment outcomes of the DR-TB component in Kitgum have been promising: although the number of patients in the program is small, since it began in 2009 there have been no defaulters, no treatment failures and no deaths. MSF puts the success down to the model of care they are using, which is comprehensive, decentralized, and community-based. In addition to the conventional components of care, two constituents have played a vital part: psychosocial counseling by trained counselors to support patients through their treatment; and the use of village health teams, who are trained, supervised and rewarded for their work.

Community-based care has been shown to be safe, practical and extremely effective for DR-TB, leading to high adherence, close follow-up and encouraging outcomes. Patients treated within their communities benefit from the practical and emotional support of friends and family in coping with the side effects of the drugs and adhering to their treatment, while increased understanding of TB within communities leads to higher detection rates and reduced stigma associated with the disease. The model of care has proved to be feasible and widely accepted—by patients, local communities and healthcare staff alike.

As the Ugandan government prepares to start treating people with DR-TB, MSF is convinced that its focus should be on providing comprehensive, decentralized, and community-based care. In this report, MSF calls on all key stakeholders to assure quality rapid TB diagnosis, treatment and care, and argues that a scale-up of the decentralized and community-based approach, including access to second-line TB drugs at district level, is the most feasible method of averting the country's impending health crisis.

DRC: Civilians and Aid Workers Victims of Renewed Fighting in the Kivus

Paris/New York, April 11, 2012—Civilians and aid workers are increasingly the targets of violence in eastern Democratic Republic of Congo (DRC), where armed conflicts and large troop movements have recently intensified, and where security risks have made it increasingly difficult to continue to provide medical care, said the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) on Wednesday.

National and international stabilization forces in DRC have never been more important, but MSF questions their effectiveness given the worsening situation.

"The situation is not stabilizing in Kivu,” said MSF program manager Dr. Marcela Allheimen. “It is deteriorating again, and has been deteriorating over the last several months. We are noticing renewed violence, but what is most alarming is the commonplace nature of violence on civilian populations and aid actors.”

Since November 2011, MSF teams have been victims of more than 15 acts of violence, including a raid last week by armed and uniformed men of an MSF house in Baraka, South Kivu Province. More seriously, on April 4, two MSF staff members—a nurse and a logistician—were kidnapped on a road near Nyanzale in North Kivu Province. They were released a few hours later.

Items such as food, money, and mobile phones are also being extorted, mostly to supply military logistics.

As a result of the heightened security risks, MSF—one of the few medical aid organizations present in North and South Kivu—has suspended its activities in Nyanzale, reduced them in Rutshuru, and has withdrawn its team in the Butembo area.

For the civilian populations, access to medical care has become even more difficult, and movement is limited due to the heightened risk for civilians. Sick people are afraid to travel to reach the health centers. Few people go to work in the fields due to lack of security, afraid they will be robbed, become victims of extortion, or worse. In some cases, civilians have been drafted to transport the belongings of armed men and there have been reports of women being held as slaves.

Despite the fragile security situation, MSF continues to have teams on the ground in North and South Kivu providing medical care, notably in Kitchanga, Mweso, Pinga, Rutshuru, Baraka, Lulimba, Kalonge, and Shabunda.