In 2014, Ukraine was one of the five countries with the highest burden of drug-resistant tuberculosis (DR-TB) in the world. Today, Ukraine is in the top 30. As the war with Russia further disrupts people’s access to healthcare, TB is an increasingly difficult disease to treat. The disease requires a comprehensive approach, with the right drugs, the right support, and uninterrupted access to healthcare.

Worldwide, controlling the spread of TB is a challenge, due to obsolete treatments, the lack of an effective vaccine and suitable diagnostic tools. However, gains have been made in recent years: in 2012, the first new TB drugs in half a century were approved for use, and in 2018, a pilot into a shorter course of treatment for DR-TB began in Ukraine.

This pilot was run by Médecins Sans Frontières (MSF), in partnership with with the Regional TB Dispensary of the Ministry of Health, the Public Health Centre, and the National TB Institute. In 2018, MSF opened one of those pilot projects at Zhytomyr Regional TB Dispensary, in Ukraine’s Zhytomyr region, to gather evidence about the safety and efficacy of a new short course all-oral regimen, in collaboration with Ukraine’s National TB Institute.
 
Five years and 300 patients later, MSF’s project concluded in November 2023. Each patient enrolled in MSF’s project had a unique story, and the success of their treatment depended on understanding their individual circumstances. The goal of the project was to keep patients motivated, reduce the length of their treatment and provide social support to overcome barriers that could impact their access to healthcare.

The right medicine is key to ensuring continuation of care

When MSF began working in Zhytomyr, newer oral drugs including bedaquiline and delamanide were not available in Ukraine, and the treatment for DR-TB included painful injections, rather than drugs taken orally. When these drugs did become available, treatment time was cut from 18-24 months to 9-12 months.

“Previously, patients living with DR-TB in Ukraine were often required to stay in hospital for many months, and sometimes even for years,” says Anna Antipenko, an MSF nurse. “This long and difficult process discouraged many patients from finishing treatment.”

For patients, the reduced length of treatment made a huge difference to their continuity of care and physical and mental health.

"Before the new medicines became available, I was treated with toxic drugs,” says Natalia, who finished her treatment three years ago. “Those drugs caused my skin to swell and crack and I was covered in wounds. I struggled even to walk.”

During her treatment at Zhytomyr Regional TB Dispensary, Natalia met her partner, Serhii. With each other's support, they never missed a day of treatment and were both successfully cured of the disease, with immeasurable benefits to their daily lives and outlooks.

“Now we cherish every moment being able to raise our children and I am no longer afraid of anything in this life," says Natalia.

Not only have the drugs delamanid and bedaquiline shortened the length of DR-TB treatment, they have also given patients whose condition is stable the opportunity to continue their treatment from home, as they can be taken without medical supervision, unlike the painful injections patients underwent previously. Being in a comfortable setting can help patients commit to long-term treatment.

Social support is key to successful treatment

“Having to take medication every day is challenging, and for those with co-morbidities, such as hepatitis C or diabetes, treatment can mean taking a dozen drugs a day,” says Antipenko. “Our goal is to keep patients motivated and support them throughout their treatment, from beginning to end.”

In order to increase the chances of a successful treatment plan, MSF social workers visit patients at home to support them in sticking to their medication regime and to help with any household needs, from providing firewood and food to helping pay utility bills.

“Supporting the patient with comprehensive care is an essential part of the project, as many  patients from Zhytomyr region need help with necessities, such as firewood for the winter, paying utility bills or receiving food and hygiene kits,” says Antipenko. “By addressing these needs, it's easier for people to focus on their treatment.”

Dismantling stigma

Even after recovering from DR-TB, many patients still face stigma associated with the disease, even from health and social workers.

“I have faced stigma and discrimination from my colleagues,” says MSF patient and father-of-two Oleksii. “Although I am no longer contagious, it is important that I finish my treatment. Then I can live a normal life with my two boys.”

To help address the stigma experienced by patients, MSF provides training sessions for both medical staff and social workers to provide information about the myths and realities of TB, and to raise awareness of treatment protocols, diagnostic methods and infection control.

The project’s legacy

When MSF teams handed over their work to the Ministry of Health, they left a valuable legacy in Zhytomyr region. This includes a biosafety level-three laboratory, constructed by MSF, for the research of potentially airborne diseases such as TB. The laboratory allows sophisticated diagnostic tests to be carried out, and it contains a GeneXpert machine capable of testing for drug-resistance in less than two hours.

The Zhytomyr project brought together Ukrainian specialists on DR-TB, as well as international experts, including microbiologists and epidemiologists from Germany, India, the Philippines and Kyrgyzstan. Overall, more than 100 experts, including doctors, nurses, epidemiologists and logisticians, worked in the project. They treated 300 patients, of whom more than three-quarters successfully completed their treatment and recovered from DR-TB.