Addressing the drug-resistant tuberculosis challenge through implementing a mixed model of care in Uganda

Treatment outcomes and predictors of success for multidrug resistant tuberculosis MDR TB in Ugandan regional referral hospitals

Multidrug-resistant tuberculosis (MDR-TB) is a form of tuberculosis caused by strains resistant to both isoniazid and rifampicin, the most critical first-line drugs. Managing MDR-TB presents substantial challenges due to prolonged and costly treatment regimens, which are less effective than those for drug-susceptible TB. These difficulties are further exacerbated in low-resource settings by inadequate healthcare infrastructure, limited diagnostic capacity, and suboptimal access to treatment. Uganda, a high-burden TB country, faces persistent challenges in meeting national MDR-TB treatment targets, with high mortality rates and unfavourable outcomes. This study evaluated the treatment outcomes and factors associated with success among MDR-TB patients in regional referral hospitals. Of the 293 registered patients, 284 were included in the analysis, with a median age of 38 years (IQR: 30-45) and a predominance of male patients (65.1%). Overall, 68.7% of patients achieved successful treatment outcomes, while 31.3% experienced unfavourable outcomes. Multivariate analysis identified weight at treatment initiation (41-49 kg) as significantly associated with poor outcomes. These findings highlight a treatment success rate below national targets, with persistent high mortality and treatment failure in several regions. Addressing these challenges requires the development of innovative therapies and personalized care strategies to improve MDR-TB management in Uganda.

Alcohol use disorder among people diagnosed with tuberculosis in a large urban case-finding project in central Uganda: prevalence, associated factors and challenges to treatment adherence

BACKGROUND

Heavy consumption of alcohol increases the risk of developing active tuberculosis (TB), contributes to delayed diagnosis and affects adherence to treatment. Within a large urban case-finding project, we aimed to determine the prevalence of and factors associated with alcohol use disorder (AUD) and to understand the challenges that people with AUD face while seeking for TB services and adhering to TB treatment.

METHODS

We carried out an explanatory sequential study in two large urban districts in Uganda. We collected quantitative data on the prevalence of alcohol use disorder using the Cut, Annoyed, Guilty, Eye opener (CAGE) tool. We used a Poisson regression model with robust variance to examine factors associated with AUD. Both the crude and adjusted prevalence risk ratios with 95% confidence intervals were presented. We then conducted two focus group discussions with persons diagnosed with both TB and AUD. Focus group discussions (FGDs) were transcribed, data were analysed inductively and coded into themes using NVIVO version 12 software.

RESULTS

Out of 325 people with TB people interviewed, 62 (18.7% 95% confidence interval [CI] 18-31%) screened positive for AUD. Majority 82.3% (51/62) were male. Being male aPR 2.32 (95% CI 1.19, 4.49) and living in an urban area aOR 1.79 (95% CI: 1.10, 2.92) were significantly associated with a positive screen. Among people who screened positive for AUD, there was a tendency towards suboptimal TB treatment outcomes, although this did not reach significance aPR 1.65 (95% CI: 0.95, 2.85). Fourteen people (eight male and six female) who screened positive for AUD attended two FGDs. These respondents often did not disclose alcohol use during TB treatment and missed clinic refill appointments due to lack of transport fares to the clinic.

CONCLUSION

A significant proportion of people with TB screened positive for AUD but did not disclose alcohol use to their healthcare workers. These patients experienced several challenges while on TB treatment. Therefore, TB care programs need to design interventions that actively assess for AUD and in order to address related challenges.

Level of tuberculosis-related stigma and associated factors in Ugandan communities

Tuberculosis (TB) stigma remains a significant barrier to TB control efforts globally, especially in countries with a high TB burden. Studies about TB stigma done in Uganda so far have been limited in scope and focused on data collected health facilities. In this study we report TB related stigma at community level for the period 2021/2022. We used the 2021/22 Lot Quality Assurance Sampling (LQAS) data from a sample of 33,349 participants across 77 districts, to measure TB stigma determine factors associated. We included demographic characteristics, knowledge and participant perspectives as our study variables. Univariable and multivariate logistic regression analyses were performed to identify factors associated with TB stigma. TB stigma was assessed as a categorical variable (below or above the median) due to the skewness of the data when fitting the scores. The data set had equal proportions of males and females. The largest age group was 20-29 years old (38.47%). Most participants were married (62.94%) and had primary level education (65.80%). The TB stigma scores were assigned on a scale from 0 to 30, with an average score of 21.67 (±8.22) and a median score of 24 (19-28). Overall, 45.48% of participants had TB stigma scores above the median. Variations in TB stigma levels were observed across different districts. Factors associated with higher TB stigma included older age, higher education levels, urban residence, and TB knowledge. To reduce TB stigma and misinformation that can make an impact on TB response, community interventions should balance increasing awareness with minimizing fear. These interventions should be well-rounded and context-specific to address disparities within communities and bolster TB control efforts in the country.

Characteristics and treatment outcomes of adolescents and young adults living with HIV with drug-resistant tuberculosis co-infection in Uganda: a retrospective cohort study

Background

Tuberculosis (TB) remains a significant global health challenge, especially among people living with HIV. Drug-resistant TB (DR-TB) complicates treatment outcomes in high-burden countries like Uganda, particularly for adolescents and young adults living with HIV (AYALH).

Objectives

We described the characteristics, treatment outcomes, and factors associated with treatment success among AYALH and DR-TB at a TB treatment unit in Mulago National Referral Hospital, Kampala, Uganda.

Design

A retrospective cohort study was conducted.

Methods

Medical records of AYALH treated for DR-TB between January 2013 and December 2021 were reviewed. Descriptive statistics and multivariable logistic regression were used to analyze treatment outcomes and associated factors.

Results

Among 327 participants (mean age: 28.2 years, SD: 4.75; 52.6% male), the treatment success rate was 65.7%. A body mass index (BMI) ⩾ 18.5 kg/m2 (adjusted odds ratio [aOR]: 0.53, 95% CI: 0.33-0.83, p = 0.005), Efavirenz-based antiretroviral therapy (ART) regimens (aOR: 0.56, 95% CI: 0.35-0.89, p = 0.014), and primary DR-TB (aOR: 0.42, 95% CI: 0.28-0.64, p < 0.001) were significantly associated with treatment success.

Conclusion

The study revealed a treatment success in only two-thirds of participants emphasizing persistent challenge of achieving optimal treatment outcomes for AYALH. The findings highlight that a higher BMI and Efavirenz-based ART regimens are significantly associated with improved treatment success pointing to the necessity for addressing nutritional needs and optimizing ART regimens to improve the management of DR-TB among AYALH.

Predictors of treatment delay among drug resistant tuberculosis patients in Uganda

BACKGROUND

Drug resistant tuberculosis (DR-TB) continues to be a significant global public health concern despite the availability of effective TB medicines. Equally, delayed DR-TB treatment initiation is associated with increased morbidity, amplified resistance, transmission risk and poor treatment outcomes. This study aimed to investigate treatment delays and identify predictors of delayed treatment initiation among DR-TB patients in Uganda.

METHOD

A retrospective study was conducted using routine DR-TB national case registration data between January 2012 and December 2019. Stata version 15 was used to run uni-variate analysis to describe patient characteristics using frequencies and percentages; bivariate analysis to identify significant differences in median times to treatment initiation; and logistic regression model was fitted, and adjusted odds ratio (AOR) with 95% confidence interval was used to identify factors associated with DR-TB treatment delay.

RESULTS

A total of 2,166 DR-TB patients were included in this study. The median treatment initiation delay was 10 days. Approximately 57% of DR-TB patients experienced delays in starting their treatment beyond the acceptable 7-day timeframe. Being diagnosed as RR-TB [AOR = 1.22; 95% CI: 1.08-1.37], and being a recurrent TB patient [AOR = 1.22; 95% CI: 1.01-1.47] were associated with treatment delays. Patients with previous history of 'lost to follow-up' (LTFU), failure and being diagnosed as Pre-XDR-TB were less inclined to delay DR-TB treatment.

CONCLUSION

Several DR-TB patients experienced treatment delay. The delay was significant among patients diagnosed as RR-TB and those with TB treatment history of recurrent TB. This highlights the need for heightened vigilance among healthcare workers when managing DR-TB patients with a history of past TB treatment and those diagnosed as RR-TB to minimize delays. Furthermore, future research should investigate a comprehensive list of variables influencing the timing of treatment initiation after diagnosis. An in-depth understanding of the effects of these factors can inform targeted interventions to optimize treatment strategies for improved DR-TB patient outcomes.

Active tuberculosis disease among people living with HIV on ART who completed tuberculosis preventive therapy at three public hospitals in Uganda

Tuberculosis (TB) preventive therapy (TPT) reduces the incidence of TB among people living with the human immunodeficiency virus (PLHIV). However, despite an increase in TPT uptake, TB/HIV coinfection remains stagnant in Uganda especially in areas of increasing HIV incidence such as the Bunyoro sub-region. This study was a retrospective review records (antiretroviral therapy [ART] files) of PLHIV who were active on ART and completed TPT in 2019/2020 at three major hospitals in the Bunyoro sub-region, Uganda: Masindi General Hospital, Hoima Regional Referral Hospital, and Kiryandongo General Hospital. The sample size (987) for each facility was determined using a proportionate sampling method to ensure the study's power and precision. Factors independently associated with acquiring TB disease post TPT were determined using modified Poisson regression analysis. An adjusted prevalence risk ratio (aPRR) with corresponding 95% confidence intervals were reported. The participants' mean age was 38.23 (±11.70) and the majority were female (64.94%). Overall, 9.63% developed active TB disease post TPT completion. In the adjusted analysis, factors associated with active TB disease were a history of an unsuppressed viral load after TPT (aPRR 4.64 (2.85-7.56), p<0.001), opportunistic infections after TPT completion (aPRR 4.31 (aPRR 2.58-7.2), p<0.001), a history of TB active TB disease (aPRR 1.60 (1.06-2.41), p = 0.026), and chronic illness during or after TPT (aPRR 1.68 (1.03-2.73), p = 0.038). To reduce the development of TB disease post TPT thereby improving the effectiveness of TPT, ART adherence should be emphasized to resolve viral suppression and active management of chronic and opportunistic infections. Further clinical management consideration and research is needed for PLHIV who receive TPT but have a previous history of TB disease.

Acceptability, Usefulness, and Ease of Use of an Enhanced Video Directly Observed Treatment System for Supporting Patients With Tuberculosis in Kampala, Uganda: Explanatory Qualitative Study

BACKGROUND

In tuberculosis (TB) control, nonadherence to treatment persists as a barrier. The traditional method of ensuring adherence, that is, directly observed therapy, faces significant challenges that hinder its widespread adoption. Digital adherence technologies such as video directly observed therapy (VDOT) are emerging as promising solutions. However, as these novel technologies gain momentum, a critical gap is the lack of comprehensive studies evaluating their efficacy and the unique experiences of patients in Africa.

OBJECTIVE

The aim of this study was to assess patients' experiences that affected acceptability, usefulness, and ease of use with an enhanced VDOT system during monitoring of TB treatment.

METHODS

We conducted individual open-ended interviews in a cross-sectional exit qualitative study in Kampala, Uganda. Thirty participants aged 18-65 years who had completed the VDOT randomized trial were purposively selected to represent variability in sex, adherence level, and HIV status. We used a hybrid process of deductive and inductive coding to identify content related to the experience of study participation with VDOT. Codes were organized into themes and subthemes, which were used to develop overarching categories guided by constructs adapted from the modified Technology Acceptance Model for Resource-Limited Settings. We explored participants' experiences regarding the ease of use and usefulness of VDOT, thereby identifying the facilitators and barriers to its acceptability. Perceived usefulness refers to the benefits users expect from the technology, while perceived ease of use refers to how easily users navigate its various features. We adapted by shifting from assessing perceived to experienced constructs.

RESULTS

The participants' mean age was 35.3 (SD 12) years. Of the 30 participants, 15 (50%) were females, 13 (43%) had low education levels, and 22 (73%) owned cellphones, of which 10 (45%) had smartphones. Nine (28%) were TB/HIV-coinfected, receiving antiretroviral therapy. Emergent subthemes for facilitators of experienced usefulness and ease of VDOT use were SMS text message reminders, technology training support to patients by health care providers, timely patient-provider communication, family social support, and financial incentives. TB/HIV-coinfected patients reported the added benefit of adherence support for their antiretroviral medication. The external barriers to VDOT's usefulness and ease of use were unstable electricity, technological malfunctions in the app, and lack of cellular network coverage in rural areas. Concerns about stigma, disease disclosure, and fear of breach in privacy and confidentiality affected the ease of VDOT use.

CONCLUSIONS

Overall, participants had positive experiences with the enhanced VDOT. They found the enhanced VDOT system user-friendly, beneficial, and acceptable, particularly due to the supportive features such as SMS text message reminders, incentives, technology training by health care providers, and family support. However, it is crucial to address the barriers related to technological infrastructure as well as the privacy, confidentiality, and stigma concerns related to VDOT.

The association of IL-17A rs2275913 single nucleotide polymorphism with anti-tuberculous drug resistance in patients with pulmonary tuberculosis

BACKGROUND

Drug-resistant  Tuberculosis (DR-TB) is a global health burden with high morbidity and mortality in developing countries including Egypt. The susceptibility to infection with DR-TB strains may be genetically determined. Several interleukin gene polymorphisms were investigated as risk factors for tuberculosis infection but focusing on their association with DR-TB was limited. Therefore, the objective of this study is to assess the association of IL 17 - 197 G > A (rs2275913) single nucleotide polymorphism (SNP) with susceptibility to DR-TB strains in comparison to drug-sensitive tuberculosis (DS-TB) strains in Egyptian patients with pulmonary TB. This cross-sectional study was conducted on 80 patients with DR-TB strains and 80 with DS-TB strains as a control group. Both age and sex were comparable among the study's groups. IL-17 - 197 G > A (rs2275913) SNP was genotyped by real-time PCR, and IL-17 serum concentration was measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The GA and AA genotype frequencies of IL 17 - 197 G > A (rs2275913) SNP were significantly higher in patients with DR-TB strains than those with DS-TB strains (p < 0.001). The frequency of the A allele was significantly (p < 0.001) higher in patients with DR-TB group (32.5%) compared to the control group (13.8%). Substantial higher serum levels of IL-17 were detected in the DR-TB group with significant association with AA and AG genotypes.

CONCLUSION

Polymorphism in IL-17 -197 G > A (rs2275913) resulted in higher serum levels of IL-17 and Egyptian patients with such polymorphism are three times at risk of infection with DR-TB strains than patients with wild type.

Cost of treatment support for multidrug-resistant tuberculosis using patient-centred approaches in Ethiopia: a model-based method

BACKGROUND

Patient and health system costs for treating multidrug-resistant tuberculosis (MDR-TB) remain high even after treatment duration was shortened. Many patients do not finish treatment, contributing to increased transmission and antimicrobial resistance. A restructure of health services, that is more patient-centred has the potential to reduce costs and increase trust and patient satisfaction. The aim of the study is to investigate how costs would change in the delivery of MDR-TB care in Ethiopia under patient-centred and hybrid approaches compared to the current standard-of-care.

METHODS

We used published data, collected from 2017 to 2020 as part of the Standard Treatment Regimen of Anti-Tuberculosis Drugs for Patients with MDR-TB (STREAM) trial, to populate a discrete event simulation (DES) model. The model was developed to represent the key characteristics of patients' clinical pathways following each of the three treatment delivery strategies. To the pathways of 1000 patients generated by the DES model we applied relevant patient cost data derived from the STREAM trial. Costs are calculated for treating patients using a 9-month MDR-TB treatment and are presented in 2021 United States dollars (USD).

RESULTS

The patient-centred and hybrid strategies are less costly than the standard-of-care, from both a health system (by USD 219 for patient-centred and USD 276 for the hybrid strategy) and patient perspective when patients do not have a guardian (by USD 389 for patient-centred and USD 152 for the hybrid strategy). Changes in indirect costs, staff costs, transport costs, inpatient stay costs or changes in directly-observed-treatment frequency or hospitalisation duration for standard-of-care did not change our results.

CONCLUSION

Our findings show that patient-centred and hybrid strategies for delivering MDR-TB treatment cost less than standard-of-care and provide critical evidence that there is scope for such strategies to be implemented in routine care. These results should be used inform country-level decisions on how MDR-TB is delivered and also the design of future implementation trials.

Prevalence and factors associated with reported adverse-events among patients on multi-drug-resistant tuberculosis treatment in two referral hospitals in Uganda

BACKGROUND

Multi-drug-resistant tuberculosis (MDR-TB) treatment involves toxic drugs that cause adverse events (AEs), which are life-threatening and may lead to death if not well managed. In Uganda, the prevalence of MDR-TB is increasingly high, and about 95% of the patients are on treatment. However, little is known about the prevalence of AEs among patients on MDR-TB medicines. We therefore estimated the prevalence of reported adverse events (AEs) of MDR-TB drugs and factors associated with AEs in two health facilities in Uganda.

METHODS

A retrospective cohort study of MDR-TB was conducted among patients enrolled at Mulago National Referral and Mbarara Regional Referral hospitals in Uganda. Medical records of MDR-TB patients enrolled between January 2015 and December 2020 were reviewed. Data on AEs, which were defined as irritative reactions to MDR-TB drugs, were extracted and analyzed. To describe reported AEs, descriptive statistics were computed. A modified Poisson regression analysis was used to determine factors associated with reported AEs.

RESULTS

Overall, 369 (43.1%) of 856 patients had AEs, and 145 (17%) of 856 had more than one. Joint pain (244/369, or 66%), hearing loss (75/369, or 20%), and vomiting (58/369, or 16%) were the most frequently reported effects. Patients started on the 24-month regimen (adj. PR = 1.4, 95%; 1.07, 1.76) and individualized regimens (adj. PR = 1.5, 95%; 1.11, 1.93) were more likely to suffer from AEs. Lack of transport for clinical monitoring (adj. PR = 1.9, 95%; 1.21, 3.11); alcohol consumption (adj. PR = 1.2, 95%; 1.05, 1.43); and receipt of directly observed therapy from peripheral health facilities (adj. PR = 1.6, 95%; 1.10, 2.41) were significantly associated with experiencing AEs. However, patients who received food supplies (adj. PR = 0.61, 95%; 0.51, 0.71) were less likely to suffer from AEs.

CONCLUSION

The frequency of adverse events reported by MDR-TB patients is considerably high, with joint pain being the most common. Interventions such as the provision of food supplies, transportation, and consistent counseling on alcohol consumption to patients at initiation treatment facilities may contribute to a reduction in the rate of occurrence of AEs.

Gender differences among patients with drug resistant tuberculosis and HIV co-infection in Uganda: a countrywide retrospective cohort study

BACKGROUND

Gender differences among patients with drug resistant tuberculosis (DRTB) and HIV co-infection could affect treatment outcomes. We compared characteristics and treatment outcomes of DRTB/HIV co-infected men and women in Uganda.

METHODS

We conducted a retrospective chart review of patients with DRTB from 16 treatment sites in Uganda. Eligible patients were aged ≥ 18 years, had confirmed DRTB, HIV co-infection and a treatment outcome registered between 2013 and 2019. We compared socio-demographic and clinical characteristics and tuberculosis treatment outcomes between men and women. Potential predictors of mortality were determined by cox proportional hazard regression analysis that controlled for gender. Statistical significance was set at p < 0.05.

RESULTS

Of 666 DRTB/HIV co-infected patients, 401 (60.2%) were men. The median (IQR) age of men and women was 37.0 (13.0) and 34.0 (13.0) years respectively (p < 0.001). Men were significantly more likely to be on tenofovir-based antiretroviral therapy (ART), high-dose isoniazid-containing DRTB regimen and to have history of cigarette or alcohol use. They were also more likely to have multi-drug resistant TB, isoniazid and streptomycin resistance and had higher creatinine, aspartate and gamma-glutamyl aminotransferase and total bilirubin levels. Conversely, women were more likely to be unemployed, unmarried, receive treatment from the national referral hospital and to have anemia, a capreomycin-containing DRTB regimen and zidovudine-based ART. Treatment success was observed among 437 (65.6%) and did not differ between the genders. However, mortality was higher among men than women (25.7% vs. 18.5%, p = 0.030) and men had a shorter mean (standard error) survival time (16.8 (0.42) vs. 19.0 (0.46) months), Log Rank test (p = 0.046). Predictors of mortality, after adjusting for gender, were cigarette smoking (aHR = 4.87, 95% CI 1.28-18.58, p = 0.020), an increase in alanine aminotransferase levels (aHR = 1.05, 95% CI 1.02-1.07, p < 0.001), and history of ART default (aHR = 3.86, 95% CI 1.31-11.37, p = 0.014) while a higher baseline CD4 count was associated with lower mortality (aHR = 0.94, 95% CI 0.89-0.99, p = 0.013 for every 10 cells/mm³ increment).

CONCLUSION

Mortality was higher among men than women with DRTB/HIV co-infection which could be explained by several sociodemographic and clinical differences.

Undernutrition and Treatment Success in Drug-Resistant Tuberculosis in Uganda

Background

Undernutrition is associated with unfavourable treatment outcomes among people with drug-resistant tuberculosis (DRTB). Factors influencing the treatment outcomes among undernourished people with DRTB are not well characterised. The aim of this study was to determine factors associated with treatment success among undernourished people with DRTB in Uganda.

Methods

We analysed data from a retrospective cohort of people with DRTB from 16 treatment sites in Uganda. We included participants with a pre-treatment body mass index (BMI) of <18.5 kilograms/meters² (kg/m²). Participants were categorised as having mild (BMI of 18.5–17 kg/m²), moderate (BMI of 16.9–16.0 kg/m²) or severe (BMI of <16.0 kg/m²) undernutrition. We performed logistic regression analysis to determine factors associated with treatment success.

Results

Among 473 people with DRTB, 276 (58.4%) were undernourished (BMI < 18.5 Kg/m²) and were included in the study. Of these, 92 (33.3%) had mild, 69 (25.0%) had moderate and 115 (41.7%) had severe undernutrition. The overall treatment success rate (TSR) for the undernourished was 71.4% (n = 197). Although the TSR was similar among participants with mild (71.7%), moderate (78.3%) and severe (67.0%) undernutrition (p = 0.258), all treatment failure cases (n =6) were among participants with severe undernutrition (p = 0.010). Cigarette smoking (odds ratio (OR) = 0.19, 95% CI 0.07–0.47, p < 0.001), urban residence (OR = 0.31, 95% CI 0.14–0.70, p = 0.005) and moderate (OR = 0.14, 95% CI 0.06–0.35, p < 0.001) and severe anaemia (OR = 0.06, 95% CI 0.01–0.29, p = 0.001) were associated with lower odds of treatment success.

Conclusion

Most undernourished people with DRTB have severe undernutrition. Smoking and anaemia are modifiable factors which upon appropriate intervention could improve treatment success. The effect of urban residence on the TSR needs to be evaluated further.

Multidisciplinary management of difficult-to-treat drug resistant tuberculosis: a review of cases presented to the national consilium in Uganda

BACKGROUND

Patients with drug resistant tuberculosis (DR-TB) with comorbidities and drug toxicities are difficult to treat. Guidelines recommend such patients to be managed in consultation with a multidisciplinary team of experts (the "TB consilium") to optimise treatment regimens. We describe characteristics and treatment outcomes of DR-TB cases presented to the national DR-TB consilium in Uganda between 2013 and 2019.

METHODS

We performed a secondary analysis of data from a nation-wide retrospective cohort of DR-TB patients with poor prognostic indicators in Uganda. Patients had a treatment outcome documented between 2013 and 2019. Characteristics and treatment outcomes were compared between cases reviewed by the consilium with those that were not reviewed.

RESULTS

Of 1,122 DR-TB cases, 189 (16.8%) cases from 16 treatment sites were reviewed by the consilium, of whom 86 (45.5%) were reviewed more than once. The most frequent inquiries (N = 308) from DR-TB treatment sites were construction of a treatment regimen (38.6%) and management of side effects (24.0%) while the most frequent consilium recommendations (N = 408) were a DR-TB regimen (21.7%) and "observation while on current regimen" (16.6%). Among the cases reviewed, 152 (80.4%) were from facilities other than the national referral hospital, 113 (61.1%) were aged ≥ 35 years, 72 (40.9%) were unemployed, and 26 (31.0%) had defaulted antiretroviral therapy. Additionally, 141 (90.4%) had hepatic injury, 55 (91.7%) had bilateral hearing loss, 20 (4.8%) had psychiatric symptoms and 14 (17.7%) had abnormal baseline systolic blood pressure. Resistance to second-line drugs (SLDs) was observed among 9 (4.8%) cases while 13 (6.9%) cases had previous exposure to SLDs. Bedaquiline (13.2%, n = 25), clofazimine (28.6%, n = 54), high-dose isoniazid (22.8%, n = 43) and linezolid (6.7%, n = 13) were more frequently prescribed among cases reviewed by the consilium than those not reviewed. Treatment success was observed among 126 (66.7%) cases reviewed.

CONCLUSION

Cases reviewed by the consilium had several comorbidities, drug toxicities and a low treatment success rate. Consilia are important "gatekeepers" for new and repurposed drugs. There is need to build capacity of lower health facilities to construct DR-TB regimens and manage adverse effects.

Discontinuation of tuberculosis treatment among children in the Kampala Capital City Authority health facilities: a mixed-methods study

Introduction

Discontinuation of tuberculosis treatment (DTT) among children in sub-Saharan Africa is a major obstacle to effective tuberculosis (TB) control and has the potential to worsen the emergence of multi-drug resistant TB and death. DTT in children is understudied in Uganda. We examined the level and factors associated with DTT among children at four large health facilities in Kampala Capital City Authority and documented the reasons for DTT from treatment supporters and healthcare provider perspectives.

Methods

We conducted a retrospective analysis of records for children < 15 years diagnosed and treated for TB between January 2018 and December 2019. We held focus group discussions with treatment supporters and key informant interviews with healthcare providers. We defined DTT as the stoppage of TB treatment for 30 or more consecutive days. We used a stepwise generalized linear model to assess factors independently associated with DTT and content analysis for the qualitative data reported using sub-themes.

Results

Of 312 participants enrolled, 35 (11.2%) had discontinued TB treatment. The reasons for DTT included lack of privacy at healthcare facilities for children with TB and their treatment supporters, the disappearance of TB symptoms following treatment initiation, poor implementation of the community-based directly observed therapy short-course (CB-DOTS) strategy, insufficient funding to the TB program, and frequent stock-outs of TB drugs. DTT was more likely during the continuation phase of TB treatment compared to the intensive phase (Adjusted odds ratio (aOR), 5.22; 95% Confidence Interval (CI), 1.76–17.52) and when the treatment supporter was employed compared to when the treatment supporter was unemployed (aOR, 3.60; 95% CI, 1.34–11.38).

Conclusion

Many children with TB discontinue TB treatment and this might exacerbate TB morbidity and mortality. To mitigate DTT, healthcare providers should ensure children with TB and their treatment supporters are accorded privacy during service provision and provide more information about TB symptom resolution and treatment duration versus the need to complete treatment. The district and national TB control programs should address gaps in funding to TB care, the supply of TB drugs, and the implementation of the CB-DOTS strategy.

Treatment outcomes of pregnant women with drug-resistant tuberculosis in Uganda: A retrospective review of 18 cases

BACKGROUND

There is a dearth of reports on drug-resistant tuberculosis (DRTB) treatment outcomes among pregnant women in tuberculosis (TB)/HIV high-burdened countries. We report treatment outcomes of 18 pregnant women with DRTB in Uganda.

METHODS

We reviewed charts of individuals who received DRTB treatment in Uganda across 16 DRTB treatment sites. We included all women who were pregnant during DRTB treatment and had a treatment outcome documented between 2013 and 2019.

RESULTS

There were 18 pregnant women with a mean age (standard deviation (SD)) of 27.5 (5.2) years, of whom 8 (44.4%) were HIV co-infected. Among these women, 12 (66.7%) had primary DRTB and 8 (44.4%) had multidrug-resistant TB. Levofloxacin (Lfx), Pyrazinamide, Cycloserine and Kanamycin (Kn) were the most (>78%) used drugs in the treatment regimen and the mean (SD) treatment duration was 17.6 (7.5) months. Elevated liver enzymes (81.8%, n = 11) and hearing loss (33.3%, n = 15) were the most frequently encountered drug adverse events. Treatment success was observed among 15 (83.3%) patients, 2 (11.1%) patients were lost to follow up and 1 (5.6%) patient died.

CONCLUSION

The treatment success among pregnant women with DRTB in Uganda was high despite a high prevalence of HIV co-infection.