The health, ethical and legal implications of non-adherence to treatment amongst patients infected with tuberculosis. (The HEAL study)
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Despite global efforts to eradicate tuberculosis (TB), it remains a significant cause of morbidity and mortality. In South Africa, healthcare represents the fourth highest area of annual expenditure, however the prevalence of TB, including drug-resistant TB and HIV-related TB remains amongst the highest in the world. The control of this infection is further compromised by patients who do not complete their treatment, thereby contributing to the development of resistant forms such as MDRTB and XDRTB. Although some success has been achieved in decreasing mortality, the eradication of TB remains challenging. A paradigm shift from the current focus on biomedical and pharmacological interventions must include ethical, human rights and legislative considerations, as the control of the disease is inextricably linked to social determinants and public health. Nonadherence to treatment extends beyond the research and development of newer drugs and requires input into the social determinants as well. Nonspecific legislation and generic policy guidelines may ultimately contribute to public health endangerment as authorities attempt to balance individual autonomy and public health rights in cases where infected persons wilfully default on treatment. More aggressive measures such as isolation and imprisonment have also not proven effective in countries that have enforced them. In this context, the dissertation explores the current impact of TB, the ethical issues, and the legislative constraints relating to the management of non-adherence to treatment. Modern-day sanatoria as a treatment umbrella for both nonadherence and social determinants is introduced, whilst ethical considerations such as social justice, equity and solidarity, are discussed within the existing legislative and policy framework. In support of the movement for sanatoria, the dissertation provides the reader with the findings of a pilot survey on the attitudes of current TB sufferers and health care workers towards this intervention. In the final analysis, it remains the collective duty of infected individuals, the general public, and both state and non -state actors to fulfil their respective roles in eradicating the disease.