Cash incentives and counselling help in fight against TB, study shows

Tuberculosis patients who receive cash incentives and counselling have a 52% lower relative risk of having an unsuccessful treatment outcome.

This was revealed in a groundbreaking study conducted by the National Institute for Communicable Diseases (NICD) in partnership with Wits University. 

The study, which was published last week in the Lancet Infectious Diseases journal, was led by Prof Nazir Ismail from Wits University and a former NICD TB centre head. 

The study's findings are critical as economic and behavioural factors lead to poor outcomes in patients with tuberculosis. South Africa has one of the highest burdens of tuberculosis worldwide, and an estimated one in five people were not recorded as having started treatment in 2023.

“Combining tuberculosis pre-test and post-test counselling with conditional cash transfers significantly reduced the risk of unsuccessful patient outcomes and improved the overall treatment success rate from 66.9% to 82.0%, bringing one of the 90—90—90 targets within reach,” said the authors. The 90—90—90 target refers to achieving a 90% tuberculosis treatment success.

The authors said a reduction of pre-treatment loss to follow-up is expected to reduce community transmission of tuberculosis, leading to lower incidence over time, a key goal of the End TB strategy. Loss to follow-up refers to people diagnosed with TB who either do not start treatment or who stop treatment during care.  

The study, a randomised controlled trial conducted across nine clinics in Johannesburg, evaluated the effects of a patient-centred intervention combining pre-test and post-test TB counselling with financial incentives on treatment adherence and outcomes. The randomised trial was done between October 2018 and March 2020.

Cash transfers of R150 were conditional upon participants in the intervention group attending their appointments within the prespecified window period, which included returning for their results and starting treatment and the monthly follow-up visits until the end of treatment. The other group of participants in the study (control group) was not offered a cash incentive.

The primary endpoint was successful patient outcome (patients who were cured or completed treatment) or unsuccessful patient outcome (pre-treatment loss-to-follow-up, on-treatment loss-to-follow-up, development of rifampicin-resistant tuberculosis while on treatment, treatment failure or death).     

The head of the TB centre at the NICD, Dr Shaheed Vally Omar, who is also the study's senior author, commended the researchers, adding that the findings showed counselling and incentives were critical in the fight against TB.

“This study findings reinforce the urgent need for patient-centred approaches that address both medical and socioeconomic barriers to care.” 

These sentiments were echoed by the NICD executive director Prof Adrian Puren, who said efforts had been intensified to manage the TB epidemic in South Africa.

“The incorporation of the study findings to ensure the success of these efforts is an important consideration,” Puren said.   

Among the key findings was that TB patients who received counselling and conditional cash transfers were significantly more likely to complete treatment successfully (82.0% vs 65.6% in the control group). 

Another key finding was that the intervention showed a substantial reduction in the relative risk of unsuccessful patient outcomes, which included not starting treatment, not completing treatment, treatment failure, drug-resistance development, or death. 

The study found that pre-treatment loss to follow-up was reduced from 15.8% to 3.9%, indicating improved engagement in care. 

The study was a collaboration between Wits, the NICD, the South African Human Sciences Research Council and University College London. It was funded by the South African Medical Research Council, the UK Medical Research Council and the Newton Fund.

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