New TB preventive treatment guidelines from The Union: What does this mean for South Africa? 

By: Aphelele Buqwana

The International Union against Tuberculosis and Lung disease has released a new report outlining updated evidence on TB Preventive Therapy with recommendations for how to protect close contacts of a person with drug-resistant TB.

TB Preventive Therapy (TPT) is a course of medication given to people at risk of acquiring TB to protect them from getting the disease. In South Africa, the uptake of TPT remains low. This is despite it being an evidence-based intervention to treat latent TB infection and prevent it from progressing to active TB.

To unpack the report in the context of South Africa, TBAC spoke to Dr Janet Giddy, a consultant from TB Proof about the significance of this report .

TB Proof is a TB advocacy organisation which has been championing the rollout of TPT, supporting policy guidance, improving awareness and working to prevent the spread of TB in communities through education and advocacy. 

In light of the global findings on TPT, how does South Africa align with or differ from what the global report outlines? 

JG: South Africa has an excellent National TB programme, which has been proactive in rolling out good TB policies based on international guidelines, and in the case of DR-TB treatment options, providing evidence based global leadership.

In 2023 the National Department of Health released a national TB policy called the “National guidelines on the Treatment of TB Infection”, commonly referred to as the TPT policy, which recommends that people who are at higher risk of TB should be offered TB Preventive Therapy, after TB disease is ruled out. The policy needs to be implemented in conjunction with the Targeted Universal TB Testing policy, which was released by the health department in 2022. 

These two new TB policies are closely linked. The universal testing policy recommends that people at higher risk of TB be tested irrespective of symptoms. If the person tests negative, they are eligible for TB Preventive Therapy. Each person with significant exposure to, or risk of having TB, should be tested and offered either preventive therapy or TB treatment. This is known as the TB test and treat approach or the status neutral approach, meaning TB prevention and care services are offered to everyone, regardless of their TB status.

 These higher risk groups are: 

• People living with HIV – they need to be tested for TB annually 
• Close contacts of people diagnosed with TB 
• People who have been treated for TB in the previous 2 years 

These new policies are primarily focused on drug sensitive TB, although the universal testing policy would also apply to people diagnosed with drug resistant TB. The preventive treatment policy has specific recommendations for drug sensitive TB preventive therapy regimens, which are shorter and more “user friendly” (e.g 3HP is taken weekly for 3 months), but no recommendation for preventive therapy for drug resistant TB.

 There is currently no official national policy related to TPT recommendations for the contacts of people with DR TB. The general clinical approach, based on published studies, is that if the index patient is fluroquinolone sensitive, then levofloxacin can be used for 6 months, and if they are not, then the TPT regimen needs to be based on the drug resistance profiles of the index patient.

The health department needs to release a guideline to enable front-line healthcare workers to effectively and confidently manage the contacts of drug-resistant TB patients, knowing that they are providing care based on official policy. The TB Think Tank Child, Adolescent and Maternal working group are currently working on a reference guide that includes recommendations for preventive therapy in contacts exposed to drug resistant TB. This will need to be signed off by the National TB Director and a circular issued before it becomes official policy.

Is there anything in the report you disagree with or feel may not apply in the South African context? 

JG: It is a good report with useful recommendations. There are two interesting points the report makes. The first relates to identifying the level of individual risk in order to establish how much a contact would benefit from preventive therapy.

 The second is evaluating and responding to social determinants in considering the risk of a person’s TB infection progressing to disease. This could include looking at things like improved nutrition and providing financial support to contacts, given the increasing evidence suggesting that these interventions can reduce the risk of developing TB disease.

South Africa does need an evidence-based guideline on how to prevent TB in household contacts of people with drug resistant TB. The WHO produced a 2024 guideline strongly recommending a 6-month course of daily levofloxacin as a TPT option for contacts. In addition to medication, nutritional and social support would also make a significant difference if it were available as an option in SA, but it appears that there is no support at provincial or national level currently for this idea.

Why is it important for South Africa to prioritise TPT? 

JG: South Africa has a serious TB burden. What is needed to end TB in SA is a “whole of society approach” as well as effectively implementing all possible evidence-based strategies to combat TB, including preventive therapy for the contacts of drug sensitive and drug-resistant TB patients.

What do you believe needs to be done to improve the uptake and implementation of TPT in the country? 

JG: Many healthcare workers are not aware of the new universal TB testing and preventive therapy policies so there needs to be ongoing training and information provided to them as well as support on how to implement the policies.

The general public also needs to be informed about both these policies as a way of demand creation. People should be coming to facilities or health providers to request TB tests as well as preventive therapy. We need a dedicated campaign on multiple public platforms to inform the public.

We need an official policy for how to protect the contacts of patients with drug resistant TB, and as part of implementation, health workers need to be trained on it.

The private sector also needs to be included in a “whole of society approach”. SA needs to urgently develop public-private partnerships around TB testing, TPT and TB treatment.

Janet Giddy is a TB survivor and works as a consultant for TB Proof. She is a Family Physician with a Masters in Public Health.

You can read the full global report here: https://theunion.org/news/managing-household-contacts-of-individuals-with-rifampicin-resistant-tuberculosis