Preventive therapy focus of San Francisco program
Rolling out DOPT in the Tenderloin
After three years of watching tuberculosis case rates go down, TB controllers in San Francisco heaved a collective sigh and turned their attention to a new subject: patients on isoniazid prophylaxis for TB infection."Now that we’ve got a good handle on active cases, we have the luxury and a little time to look at prevention," says Tony Paz, program manager for the city’s office of TB control, echoing a theme of TB controllers around the nation. The result is that the city recently launched a new two-year demonstration project in directly observed preventive therapy (DOPT).
One reason TB controllers didn’t hesitate was that a similar project was inaugurated in 1991, providing DOPT at most of its methadone maintenance sites. The methadone program has shown cost-effective results, Paz says.
Overall, the city’s completion rates for preventive therapy already stand at a respectable 70% to 73%, not far from the 75% figure the Centers for Disease Control and Prevention recommends. Even so, TB controllers decided they wanted to try to nudge the numbers upward a few more points.
To do that, an analysis suggested they’d have to go after a specific problem area. "The folks giving the most problems were coming from substance-abuse sites," Paz says. In those sites, completion rates were only about 45%; by comparison, foreign-born referrals posted rates of 80%.
Using DNA fingerprinting, the city also had established that the same group of substance abusers was responsible for most of the ongoing transmission of disease. "It’s taking place in the U.S.-born, homeless, chemically using folks with HIV risk factors," Paz says. Transmission didn’t appear to be the result of patients not completing therapy, Paz adds, "When we get a case, we latch onto them."
All evidence pointed to the conclusion that members of an especially vulnerable population who were already infected with TB were breaking down with active disease and transmitting it to others. "If we’re going to break the camel’s back, this is where we need to move next," says Paz.
The decision was made to target only the most vulnerable members of the problem group — those dually infected with TB and HIV. The reasoning was simple, Paz says, "We can’t do everything."
The easy part was knowing where to go to find the problem.
In San Francisco’s Tenderloin district, together with a neighboring district to the south, on the other side of Market Street — known simply as "south of Market" — are longstanding hot spots for TB, Paz says. There, case rates typically soar to Third-World heights: between 200 and 300 per 100,000. Each district spans an area of about 12 square blocks, and each is home to about 20,000 people, says Paz.
Both districts are well stocked with cheap housing, including at least 200 single-room-occupancy hotels, or SROs, many with 50 to 200 units apiece. The flophouses draw not only a motley mix of prostitutes and drug abusers but also throngs of foreign-born newcomers to the city — including Filipinos, Latinos, Vietnamese, and other Southeast Asians — who often live jammed several families to the room, with a hotplate doing duty for a kitchen, Paz says.
"On one street corner, you’ll see drug deals, and across the street a produce market run by immigrants," Paz says. "The mixture is amazing. It’s a place where a lot of us enjoy working because there’s so much life." It’s also the perfect breeding ground for the transmission of TB and HIV, he adds.
A captive audience of 10,000 junkies
The city began its new project by invoking its ties to community-based organizations (CBOs). Principal among them is Target Cities, a substance-abuse intake facility which last year processed and referred about 7,000 clients to various facilities for treatment. This year, the agency expects to provide referrals for as many as 10,000 people. "There, you have a captive audience," Paz says. "We figured, why not grab them and identify those who are dually infected?"The SROs that characterize the Tenderloin/ south-of-Market districts have provided another ready-made focus for the DOPT project, Paz says. "If the SRO houses a group of high-risk folks, speed shooters, or crack abusers or whatever, we will screen and treat the whole hotel, and offer DOPT to everyone," Paz says.
Because many foreign-born newcomers turn to day labor for a source of income, and because they too are at risk for dual infection, they have been recruited for DOPT as well. At day labor sites, where would-be workers gather at the crack of dawn on street corners awaiting employment, "we’ve run into some bumps," Paz says. "For one thing, how do we deliver meds at 6 o’clock in the morning? Also, getting this group to trust us and come get screened took a lot of work."
Again, it helped to hook up with a CBO that was already providing services to the target audience, Paz says. "We provided coffee, food, Wendy’s coupons; we had some culturally appropriate raffles with door prizes; and we brought in some mobile X-ray units."
City jails proved another reliable source of people at risk for dual infection. "They’re getting isoniazid in jail, but once they’re released, they fall through the cracks," Paz says. "Now, before they get released, we make sure they know our [outreach] worker, and that they know where we are and that we’ve bonded. We pick them up and bring them to our clinic and kind of wrap our arms around them, and say, OK, now you’re gonna be with us.’"
All the other carrots’
To work, the DOPT program for inmates has got to supply incentives in good measure, Paz adds. In addition to isoniazid and a warm welcome at the community clinic, newly released prisoners get bus tokens, sandwiches and soup, referrals, and "all the other carrots," says Paz.Housing and help with chemical dependency when indicated are proffered for substance abusers. "Just to offer DOPT alone is not gonna do it," says Paz. "You got to go the extra mile."
It helps that in the Tenderloin/south-of-Market districts, TB Control has already established itself as a presence, with a satellite clinic and a social worker who, Paz says, works according to a "harm reduction" model.
"Instead of saying how these people are messed up, we try to identify their strengths," explains Paz. "Because anyone who can survive out there has got to have strengths. We find those strengths and try to work with them."
Hiring outreach workers wise to the ways of the streets is the DOPT program’s biggest budget item but will also prove to be its biggest strength, Paz predicts. "You have to make yourselves known," he says. "That way, people can say, Hey, the TB folks are looking for you.’ It’s just a matter of getting out there on the streets."
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