People with HIV/AIDS in developing countries become stigmatised and impoverished by their disease. How can health systems deliver effective care to the most vulnerable people? TB is another impoverishing disease requiring complex long-term care. What can we learn from a well-functioning DOTS programme for TB?

In Malawi, the WHO's directly-observed treatment, short-course (DOTS) strategy for TB treatment has been implemented for two decades and consists of:

• diagnosis in the general health service, using sputum microscopy
• standardised short-course drug treatment (minimum eight months) supervised primarily at health facilities but increasingly also in the home
• regular uninterrupted drug supplies
• accurate record-keeping, supervision and programme evaluation
• government commitment to TB control.

The TB Equity Project (developed by the Malawi National TB Programme and the Liverpool School of Tropical Medicine) investigated whether TB treatment is accessible to poor and vulnerable Malawians. The research included focus groups, semi-structured and in-depth interviews, a patient survey, operational research and mapping of health facility usage and TB cases against indicators of poverty. It identified significant barriers to access to TB care and ways to tackle these problems. It also showed that:

• The poor have the highest burden of illness and the least access to TB services.
• People with TB seek care from various sources, including shops and private and traditional practitioners.
• Diagnostic procedures have developed around specific tests for infectious cases rather than patients' needs. Patients have to visit the hospital many times for diagnosis (consultation, laboratory tests, X-rays) and supervision of treatment.

The research has implications for each component of a comprehensive care package for HIV/AIDS:

• Care for HIV-related infections (including TB) - train community health workers to treat infections based on their symptoms, even if HIV tests are unavailable
• Voluntary counselling and testing - provide resources for services which are close to communities, backed up by laboratory quality assurance
• Care and support within the community - involve private practitioners from the formal and traditional sectors
• Anti-retroviral drugs (ARVs) - engage patients and communities in the design, implementation and monitoring of services.

Even within a well-functioning DOTS programme such as this one, poor and vulnerable TB patients can be lost or missed altogether. To ensure equity in access, TB services must be patient-centred. The same principles will apply to the provision of care for HIV/AIDS.

Source(s):
Insights Health #2: Delivering the goods Full document.

id21 Research Highlight: 14 March 2002

Further Information:
Bertie Squire
Liverpool School of Tropical Medicine
Liverpool L3 5QA
UK

Tel: +44 (0)151 708 9393
Fax: +44 (0)151 707 9193
Contact the contributor: sbsquire@liv.ac.uk

Liverpool School of Tropical Medicine (LSTM), UK

Other related links:
Follow id21's email discussion on access to HIV treatment online.

See id21's collection of links relevant to HIV/AIDS.