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Iruedo JO, Pather MK. Lived experiences of patients and families with decentralised drug-resistant tuberculosis care in the Eastern Cape, South Africa. Afr J Prim Health Care Fam Med 2023; 15:e1-e16. [PMID: 38197684 PMCID: PMC10784182 DOI: 10.4102/phcfm.v15i1.4255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND South Africa adopted the decentralised Drug Resistant Tuberculosis (DR-TB) care model in 2011 with a view of improving clinical outcomes. AIM This study explores the experiences and perceptions of patients and family members on the effectiveness of a decentralised community DR-TB care model in the Oliver Reginald Kaizana (OR) Tambo district municipality of the Eastern Cape, South Africa. METHOD In this phenomenological qualitative research design, a semi-structured interview with prompts was conducted on 30 participants (15 patients and 15 family members). Framework approach to thematic content analysis was adopted for qualitative data analysis. RESULTS Four themes emerged from the patients' interviews: adequate knowledge of DR-TB and its transmission, fear of death and isolation, long travel distances, and exorbitant transportation cost. A 'ready' health system influenced the effectiveness of community DR-TB management, while interviews with family members yielded five themes: misconceptions about DR-TB, rapid diagnosis and adherence counselling, long travel distances, activated healthcare workers, and little role of traditional healer. CONCLUSION A perceived effectiveness of a community DR-TB care model in the OR Tambo district was demonstrated through the quality and comprehensiveness of care rendered by a 'ready' health system with activated health care workers (HCWs) who provided robust support and adequate knowledge of DR-TB and its treatment/side effects. However, misconceptions about DR-TB, long travel distances to treatment facilities, high cost of transportation and stigma remained challenging for most patients and family members.Contribution: This study provides insight into the lived experiences of a decentralised community DR-TB care model in the OR Tambo district in 2020.
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Affiliation(s)
- Joshua O Iruedo
- Department of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town.
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Myburgh H, Baloyi D, Loveday M, Meehan SA, Osman M, Wademan D, Hesseling A, Hoddinott G. A scoping review of patient-centred tuberculosis care interventions: Gaps and opportunities. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001357. [PMID: 36963071 PMCID: PMC10021744 DOI: 10.1371/journal.pgph.0001357] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/20/2022] [Indexed: 02/05/2023]
Abstract
Tuberculosis (TB) is a leading cause of death globally. In 2015, the World Health Organization hailed patient-centred care as the first of three pillars in the End TB strategy. Few examples of how to deliver patient-centred care in TB programmes exist in practice; TB control efforts have historically prioritised health systems structures and processes, with little consideration for the experiences of people affected by TB. We aimed to describe how patient-centred care interventions have been implemented for TB, highlighting gaps and opportunities. We conducted a scoping review of the published peer-reviewed research literature and grey literature on patient-centred TB care interventions between January 2005 and March 2020. We found limited information on implementing patient-centred care for TB programmes (13 research articles, 7 project reports, and 19 conference abstracts). Patient-centred TB care was implemented primarily as a means to improve adherence, reduce loss to follow-up, and improve treatment outcomes. Interventions focused on education and information for people affected by TB, and psychosocial, and socioeconomic support. Few patient-centred TB care interventions focused on screening, diagnosis, or treatment initiation. Patient-centred TB care has to go beyond programmatic improvements and requires recognition of the diverse needs of people affected by TB to provide holistic care in all aspects of TB prevention, care, and treatment.
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Affiliation(s)
- Hanlie Myburgh
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Amsterdam, The Netherlands
| | - Dzunisani Baloyi
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marian Loveday
- HIV and other Infectious Diseases Research Unit (HIDRU), South African Medical Research Council (SAMRC), Cape Town, South Africa
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
| | - Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Human Sciences, Faculty of Education, Health & Human Sciences, University of Greenwich, London, United Kingdom
| | - Dillon Wademan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Wu Y, Zhang Y, Wang Y, Wei J, Wang W, Duan W, Tian Y, Ren M, Li Z, Wang W, Zhang T, Wu H, Huang X. Bedaquiline and Linezolid improve anti-TB treatment outcome in drug-resistant TB patients with HIV: A systematic review and meta-analysis. Pharmacol Res 2022; 182:106336. [PMID: 35779814 DOI: 10.1016/j.phrs.2022.106336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES We aimed to assess the effect of second-line anti-TB treatment and determine which drugs can achieve the greatest clinical benefit for DR-TB-HIV patients by comparing multiple chemotherapy regimens, to provide a basis for evidence-based practice. METHODS We searched three electronic databases (PubMed, Web of Science and Cochrane) for related English studies published since 2010. A random-effect model was used to estimate the pooled result for the treatment outcomes. Subgroup analysis based on possible factors, such as ART, baseline CD4 T-cell count, treatment regimens, and profiles of drug resistance, was also conducted to assess factors for favorable outcome. Outcomes were treatment success and mortality. RESULTS 38 studies, 40 cohorts with 9279 patients were included. The pooled treatment success, mortality, treatment failure, and default rates were 57.5 % (95 % CI 53.1-61.9), 21 % (95 % CI 17.8-24.6), 4.8 % (95 % CI 3.5-6.5), and 10.7 % (95 % CI 8.7-13.1), respectively, in patients with DR-TB and HIV co-infection. Subgroup analysis showed that BDQ and LZD based regimen, and ≥ 2 Group A drugs were associated with a higher treatment success rate. Besides, higher CD4 T-cell count at baseline was also correlated with higher treatment success rate, too. CONCLUSIONS Suboptimal anti-TB outcomes underlining the need to expand the application of effective drugs and better regimen in high HIV setting. BDQ and LZD based all-oral regimen and early ART could contribute to higher treatment success, particularly among XDR-TB-HIV patients. Given that all included studies were observational, our findings emphasize the need for high-quality studies to further investigate the optimal treatment regimen for DR-TB-HIV.
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Affiliation(s)
- Yaxin Wu
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Yingying Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Jiaqi Wei
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China; Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing100069, China
| | - Wenjing Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Wenshan Duan
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Yakun Tian
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Meixin Ren
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Zhen Li
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China; Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing100069, China
| | - Wen Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Tong Zhang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Hao Wu
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Xiaojie Huang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China.
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Makabayi-Mugabe R, Musaazi J, Zawedde-Muyanja S, Kizito E, Namwanje H, Aleu P, Charlet D, Freitas Lopez DB, Brightman H, Turyahabwe S, Nkolo A. Developing a patient-centered community-based model for management of multi-drug resistant tuberculosis in Uganda: a discrete choice experiment. BMC Health Serv Res 2022; 22:154. [PMID: 35123467 PMCID: PMC8817775 DOI: 10.1186/s12913-021-07365-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The advent of all-oral regimens for the management of multi-drug resistant tuberculosis (MDR-TB) makes the implementation of community-based directly observed therapy (CB-DOT) a possibility for this group of patients. We set out to determine patient preferences for different attributes of a community-based model for the management of MDR-TB in Uganda.
Methods
The study was conducted at five tertiary referral hospitals. We used a parallel convergent mixed methods study design. To collect quantitative data, we conducted a discrete choice experiment (DCE) with three different attributes of community-based care (DOT provider, location of care, and type of support) combined into eight choice sets, each with two options and an opt-out. We elicited patient reasons for selection of each choice set using qualitative methods. We fitted a mixed logit choice model to determine patient preferences for different attributes of community-based care and estimated the relative importance of each attribute using the range method. and used deductive thematic analysis to understand the reasons for the choices made.
Results
From December 2019 to January 2020, we interviewed 103 patients with MDR-TB. We found that all the three attributes considered were important predicators of choice. The relative importance of each attribute was as follows; the type of additional support (relative importance 36.2%), the location of treatment delivery (33.5%), and the type of DOT provider (30.3%). Participants significantly valued treatment delivered by community health workers (CHWs) or expert clients over that delivered by a family member, treatment delivered at home over that delivered at the workplace, and monthly travel vouchers as the form of additional support over phone call or SMS reminders. Subgroup analyses showed significant differences in preference across HIV status, age groups and duration on MDR-TB treatment, but not across gender.
The preferred model consisted of a CHW giving DOT at home and travel vouchers to enable attendance of monthly clinic follow-up visits to tertiary referral hospitals for treatment monitoring. Qualitative interviews revealed that patients perceived CHWs as knowledgeable and able to offer psychosocial support. Patients also preferred to take medication at home to save both time and money and lower the risk of facing TB stigma.
Conclusion
People with MDR-TB prefer to be supported to take their medicine at home by a member of their community. The effectiveness of this model of care is being further evaluated.
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Park S, Moon N, Oh B, Park M, Kang K, Sentissi I, Bae SH. Improving Treatment Adherence with Integrated Patient Management for TB Patients in Morocco. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18199991. [PMID: 34639291 PMCID: PMC8507615 DOI: 10.3390/ijerph18199991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/08/2021] [Accepted: 09/20/2021] [Indexed: 11/16/2022]
Abstract
In Morocco, there are challenges in the management of high-risk tuberculosis (TB) patients, including paper-based management and a shortage of healthcare workers related to TB. Additionally, TB management has not been accounted for in various patient types, which affects treatment adherence. This study aims to examine the delivery model of TB management and the outcomes of an integrated patient management system that uses a patient-centered and community-based approach, along with mobile health technology. A total of 3605 TB patients were enrolled in this program in Morocco’s five prefectures (Rabat, Salé, Kénitra, Khemisset, Skhirat–Témara) from January 2018 to December 2019. Patients were managed based on demographic characteristics, socioeconomic status, areas (rural or urban), health literacy levels, and distance to primary health centers. Our mobile health intervention “smart pillbox” was interposed with high-risk TB patients, along with patient education. The rate of successful treatment was 92.2%, which was higher than the national rate (88%). The “lost to follow-up” rate was 4.1%, which was significantly lower than the existing non-adherence rate of 7.9%. Therefore, integrated patient management for TB patients in Morocco is more effective than the existing conventional programs. This comprehensive approach provides an alternative method for countries with limited resources.
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Affiliation(s)
- Seup Park
- Global Care International, Seoul 08377, Korea; (S.P.); (N.M.); (B.O.); (M.P.)
| | - Narae Moon
- Global Care International, Seoul 08377, Korea; (S.P.); (N.M.); (B.O.); (M.P.)
| | - Byungkwon Oh
- Global Care International, Seoul 08377, Korea; (S.P.); (N.M.); (B.O.); (M.P.)
| | - Miyeon Park
- Global Care International, Seoul 08377, Korea; (S.P.); (N.M.); (B.O.); (M.P.)
| | | | - Ilham Sentissi
- Chief Public Health Service and Epidemiological Surveillance, Moroccan League Against Tuberculosis (Ligue Marocaine de Lute Contre la Tuberculosis, LMCT), Rabat 10000, Morocco;
| | - Sung-Heui Bae
- College of Nursing, Graduate Program in System Health Science and Engineering, Ewha Womans University, Seoul 03760, Korea
- Correspondence: ; Tel.: +82-02-3277-2767
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Daftary A, Mondal S, Zelnick J, Friedland G, Seepamore B, Boodhram R, Amico KR, Padayatchi N, O'Donnell MR. Dynamic needs and challenges of people with drug-resistant tuberculosis and HIV in South Africa: a qualitative study. Lancet Glob Health 2021; 9:e479-e488. [PMID: 33740409 PMCID: PMC8009302 DOI: 10.1016/s2214-109x(20)30548-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/18/2020] [Accepted: 12/15/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is little evidence of patient acceptability for drug-resistant tuberculosis (DRTB) care in the context of new treatment regimens and HIV co-infection. We aim to describe experiences of DRTB-HIV care among patients in KwaZulu-Natal province, South Africa. METHODS In this qualitative study using Bury's framework for chronic illness, we conducted 13 focus groups at a tertiary hospital with 55 patients co-infected with DRTB and HIV (28 women, 27 men) who were receiving new bedaquiline-based treatment for DRTB, concurrent with antiretroviral therapy. Eligible patients were consenting adults (aged >18 years) with confirmed DRTB and HIV who were enrolled into the PRAXIS study within 2 weeks of initiating bedaquiline-based treatment for DRTB. Participants were recruited from the PRAXIS cohort to participate in a focus group based on their time in DRTB treatment: early (2-6 weeks after treatment initiation), middle (2-6 months after discharge or treatment initiation if never hospitalised), and late (>6 months after treatment initiation). Focus groups were carried out in isiZulu language, audio recorded, and translated to English within 4 weeks. Participants were asked about their experiences of DRTB and HIV care and treatment, and qualitative data were coded and thematically analysed. FINDINGS From March, 2017, to June, 2018, distinctive patient challenges were identified at four critical stages of DRTB care: diagnosis, marked by centralised hospitalisation, renunciation from routine life, systemic stigmatisation and, for patients with longstanding HIV, renewed destabilisation; treatment initiation, marked by side-effects, isolation, and social disconnectedness; discharge, marked by brief respite and resurgent therapeutic and social disruption; and continuity, marked by deepening socioeconomic challenges despite clinical recovery. The periods of diagnosis and discharge into the community were particularly difficult. Treatment information and agency in decision making was a persistent gap. Sources of stigmatisation shifted with movement between the hospital and community. Resilience was built by connecting to peers, self-isolating, financial and material security, and a focus on recovery. INTERPRETATION People with DRTB and HIV undergo disruptive, life-altering experiences. The lack of information, agency, and social protections in DRTB care and treatment causes wider-reaching challenges for patients compared with HIV. Decentralised, community, peer-support, and differentiated care models for DRTB might be ameliorative and help to maximise the promise of new regimens. FUNDING US National Institutes of Health. TRANSLATION For the isiZulu translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada; Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.
| | - Shinjini Mondal
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Jennifer Zelnick
- Graduate School of Social Work, Touro College and University System, New York, NY, USA
| | | | - Boitumelo Seepamore
- Department of Social Work, University of KwaZulu-Natal, Durban, South Africa
| | - Resha Boodhram
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - K Rivet Amico
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Nesri Padayatchi
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Max R O'Donnell
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
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The effects of MDR/RR-TB treatment on HIV disease: A systematic review of literature. PLoS One 2021; 16:e0248174. [PMID: 33667271 PMCID: PMC7935310 DOI: 10.1371/journal.pone.0248174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 02/19/2021] [Indexed: 11/19/2022] Open
Abstract
Background Multidrug-resistant or rifampicin-resistant tuberculosis (MDR/RR-TB) and human immunodeficiency virus (HIV) co-infection are a deadly combination. While evidence on the effects of HIV co-infection on MDR/RR-TB treatment outcomes is well-documented, little published evidence describes the effects of MDR/RR-TB treatment on HIV disease. Methods We conducted a review of literature published prior to June 2020. We searched Pubmed, CINAHL, and EMBASE using variations of the terms “multidrug-resistant tuberculosis,” “HIV,” and either “CD4” or “viral load.” Two reviewers independently completed title and abstract screening, full-text screening, article evaluation, and data extraction. We also included five published articles evaluated as evidence by the World Health Organization (WHO) in preparation for the 2019 MDR/RR-TB treatment guideline update. Results A total of 459 references were returned, with 362 remaining after duplicate removal. Following article screening, six manuscripts were included. Articles reported CD4 count and/or viral load results for MDR/RR-TB and HIV co-infected patients during and/or after MDR/RR-TB treatment. The additional five references identified from the WHO guideline revision did not report HIV disease indicators after MDR/RR-TB initiation. Conclusion There is a paucity of evidence on HIV disease indicators following MDR/RR-TB treatment. Researchers should report longitudinal HIV disease indicators in co-infected patients in publications.
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Bakare AM, Udunze OC, Bamidele JO, Omoniyi A, Osman E, Daniel OJ. Outcome of community-initiated treatment of drug-resistant tuberculosis patients in Lagos, Nigeria. Trans R Soc Trop Med Hyg 2021; 115:1061-1065. [PMID: 33427297 PMCID: PMC8416778 DOI: 10.1093/trstmh/traa188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/27/2020] [Accepted: 12/22/2020] [Indexed: 11/14/2022] Open
Abstract
Background With the improvement in the capacity to diagnose multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) patients due to the increased number of GeneXpert machines in Nigeria, the number of patients diagnosed surpassed the bed capacity at MDR-TB treatment centres. Community DR-TB treatment is an important option to improve access to care for MDR/RR-TB patients. However, few studies have determined the outcome of community management of MDR-TB patients, which this study aims to address. Methods We conducted a retrospective study of MDR/RR-TB patients initiated on treatment in the community in Lagos, Nigeria, between 1 January 2015 and 31 December 2016. Data were retrieved from DR-TB treatment cards/registers. The treatment outcomes of these patients were assessed at the end of treatment and categorized according to national TB guidelines. Results A total of 150 DR-TB patients commenced treatment during the study period. Adherence was 64.7%, with the majority of patients experiencing mild (56.5%) adverse drug events. Treatment was successful in 70% of patients. The only predictor of successful treatment was treatment adherence. Conclusions The study shows that community initiation of MDR-TB treatment is feasible and results in a high treatment success rate. Adherence counselling before and during treatment is essential for a favourable treatment outcome.
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Affiliation(s)
| | - Obioha C Udunze
- Damien Foundation Belgium Nigeria project, Lagos State Nigeria
| | - Janet O Bamidele
- Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital Sagamu, Ogun State, Nigeria
| | | | - Eltayeb Osman
- Damien Foundation Belgium Nigeria project, Lagos State Nigeria
| | - Olusoji J Daniel
- Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital Sagamu, Ogun State, Nigeria
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Kasozi S, Kirirabwa NS, Kimuli D, Luwaga H, Kizito E, Turyahabwe S, Lukoye D, Byaruhanga R, Chen L, Suarez P. Addressing the drug-resistant tuberculosis challenge through implementing a mixed model of care in Uganda. PLoS One 2020; 15:e0244451. [PMID: 33373997 PMCID: PMC7772013 DOI: 10.1371/journal.pone.0244451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 12/09/2020] [Indexed: 12/02/2022] Open
Abstract
Worldwide, Drug-resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the clinical management capacity thereby causing ethical challenges. In Sub-Saharan Africa, treatment is either inadequate or lacking and some diagnosed patients are on treatment waiting lists. In Uganda, various health system challenges impeded scale-up of DR-TB care in 2012; only three treatment initiation facilities existed, with only 41 of the estimated 1010 RR-TB/MDR-TB cases enrolled on treatment yet 300 were on the waiting list and there was no DR-TB treatment scale-up plan. To scale up care, the National TB and leprosy Program (NTLP) with partners rolled out a DR-TB mixed model of care. In this paper, we share achievements and outcomes resulting from the implementation of this mixed Model of DR-TB care. Routine NTLP DR-TB program data on treatment initiation site, number of patients enrolled, their demographic characteristics, patient category, disease classification (based on disease site and human immunodeficiency virus (HIV) status), on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART) statuses, culture results, smear results and treatment outcomes (6, 12, and 24 months) from 2012 to 2017 RR-TB/MDR-TB cohorts were collected from all the 15 DR-TB treatment initiation sites and descriptive analysis was done using STATA version 14.2. We presented outcomes as the number of patient backlog cleared, DR-TB initiation sites, RR-TB/DR-TB cumulative patients enrolled, percentage of co-infected patients on the six, twelve interim and 24 months treatment outcomes as per the Uganda NTLP 2016 Programmatic Management of drug-resistant Tuberculosis (PMDT) guidelines (NTLP, 2016). Over the period 2013–2015, the RR-TB/MDR-TB Treatment success rate (TSR) was sustained between 70.1% and 74.1%, a performance that is well above the global TSR average rate of 50%. Additionally, the cure rate increased from 48.8% to 66.8% (P = 0.03). The Uganda DR-TB mixed model of care coupled with early application of continuous improvement approaches, enhanced cohort reviews and use of multi-disciplinary teams allowed for rapid DR-TB program expansion, rapid clearance of patient backlog, attainment of high cumulative enrollment and high treatment success rates. Sustainability of these achievements is needed to further reduce the DR-TB burden in the country. We highly recommend this mixed model of care in settings with similar challenges.
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Affiliation(s)
- Samuel Kasozi
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
| | | | - Derrick Kimuli
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
- * E-mail:
| | - Henry Luwaga
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
| | - Enock Kizito
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
| | - Stavia Turyahabwe
- National Tuberculosis and Leprosy Program, Ministry of Health, Kampala, Uganda
| | - Deus Lukoye
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
| | | | - Lisa Chen
- Curry International Tuberculosis Center (UCSF/CITC), University of California, San Francisco, San Francisco, California, United States of America
| | - Pedro Suarez
- Management Sciences for Health, Arlington, Virginia, United States of America
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10
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Wen S, Yin J, Sun Q. Impacts of social support on the treatment outcomes of drug-resistant tuberculosis: a systematic review and meta-analysis. BMJ Open 2020; 10:e036985. [PMID: 33033087 PMCID: PMC7545632 DOI: 10.1136/bmjopen-2020-036985] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To assess the effectiveness of social support on treatment success promotion or lost to follow-up (LTFU) reduction for patients with drug-resistant tuberculosis (DR-TB). DESIGN We searched Pubmed, Web of Science, Embase, Scopus and Medline databases until 18 June 2020 for interventional or mixed-method studies which reported social support and treatment outcomes of DR-TB patients. Two independent reviewers extracted data and disagreements were resolved by consensus with a third reviewer. Random-effects meta-analysis was performed to calculate the OR and 95% CI for the effects of social support on the improvement of treatment outcomes and the heterogeneity and risk of bias were assessed. SETTING Low-income and middle-income countries. PARTICIPANTS DR-TB patients. OUTCOMES Treatment success is defined as the combination of the cured and treatment completion, and LTFU is measured as treatment being interrupted for two consecutive months or more. RESULTS Among 173 articles selected for full-text review, 162 were excluded through independent review (kappa=0.87) and 10 studies enrolling 1621 DR-TB patients in eight countries were included for qualitative analysis. In these studies, the most frequently introduced social support was material support (10 studies), followed by informational (eight studies), emotional (seven studies) and companionship support (four studies). Seven studies that reported treatment outcomes in both intervention arm and control arm are qualified for meta-analysis. An encouraging improvement on treatment success rate (OR: 2.58; 95% CI: 1.80 to 3.69) was found when material support was integrated into social support packages and no heterogeneity was observed (I1 of 0%, Q test p=0.72). Reduction on LTFU rate (OR: 0.17; 95% CI: 0.05 to 0.55) was also noted when material support was available but substantial heterogeneity was found (I2 of 80%, Q test p=0.002). CONCLUSION Material support appeared feasible and effective to improve treatment success for DR-TB patients combined with other social support interventions. PROSPERO REGISTRATION NUMBER CRD42019140824.
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Affiliation(s)
- Shuqin Wen
- Centre for Health Management and Policy Research, School of Public Health, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Jia Yin
- Centre for Health Management and Policy Research, School of Public Health, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Qiang Sun
- Centre for Health Management and Policy Research, School of Public Health, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
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11
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Sinha P, Carwile M, Bhargava A, Cintron C, Acuna-Villaorduna C, Lakshminarayan S, Liu AF, Kulatilaka N, Locks L, Hochberg NS. How much do Indians pay for tuberculosis treatment? A cost analysis. Public Health Action 2020; 10:110-117. [PMID: 33134125 DOI: 10.5588/pha.20.0017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/25/2020] [Indexed: 11/10/2022] Open
Abstract
Setting India's National Tuberculosis Elimination Programme (NTEP) covers diagnostic and therapeutic costs of TB treatment. However, persons living with TB (PLWTB) continue to experience financial distress due to direct costs (payment for testing, treatment, travel, hospitalization, and nutritional supplements) and indirect costs (lost wages, loan interest, and cost of domestic helpers). Objective To analyze the magnitude and pattern of TB-related costs from the perspective of Indian PLWTB. Design We identified relevant articles using key search terms ('tuberculosis,' 'India,' 'cost,' 'expenditures,' 'financing,' 'catastrophic' and 'out of pocket') and calculated variance-weighted mean costs. Results Indian patients incur substantial direct costs (mean: US$46.8). Mean indirect costs (US$666.6) constitute 93.4% of the net costs. Mean direct costs before diagnosis can be up to four-fold that of costs during treatment. Treatment in the private sector can result in costs up to six-fold higher than in government facilities. As many as one in three PLWTB in India experience catastrophic costs. Conclusion PLWTB in India face high direct and indirect costs. Priority interventions to realize India's goal of eliminating catastrophic costs from TB include decreasing diagnostic delays through active case finding, reducing the need for travel, improving awareness and perception of NTEP services, and ensuring sufficient reimbursement for inpatient TB care.
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Affiliation(s)
- P Sinha
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, MA, USA
| | - M Carwile
- Department of Global Health, Boston University School of Public Health, MA, USA
| | - A Bhargava
- Department of Medicine, Yenepoya Medical College, Mangalore, India.,Department of Medicine, McGill University, Montreal, Quebec, Canada.,Center for Nutrition Studies, Yenepoya (Deemed to be University), Mangalore, India
| | - C Cintron
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, MA, USA
| | - C Acuna-Villaorduna
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, MA, USA
| | - S Lakshminarayan
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - A F Liu
- Department of Gastroenterology, Brigham and Women's Hospital, Boston, MA, USA
| | - N Kulatilaka
- Susilo Institute for Ethics in a Global Economy, Boston University Questrom School of Business, Boston, MA, USA
| | - L Locks
- Department of Health Sciences, Sargent College, Boston University College of Health & Rehabilitation Sciences, Boston, MA, USA
| | - N S Hochberg
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, MA, USA.,Department of Epidemiology, Boston University School of Public Health, MA, USA
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12
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Burtscher D, Juul Bjertrup P, Vambe D, Dlamini V, Mmema N, Ngwenya S, Rusch B, Kerschberger B. 'She is like my mother': Community-based care of drug-resistant tuberculosis in rural Eswatini. Glob Public Health 2020; 16:911-923. [PMID: 32816634 DOI: 10.1080/17441692.2020.1808039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with drug-resistant tuberculosis (DR-TB) have received community-based care in Eswatini since 2009. Trained and compensated community treatment supporters (CTSs) provide directly observed therapy (DOT), injectables and psychological support. We examined the acceptability of this model of care among DR-TB patients, including the perspective of family members of DR-TB patients and their CTSs in relation to the patient's experience of care and quality of life. This qualitative research was conducted in rural Eswatini in February 2018. DR-TB patients, CTSs and family members participated in in-depth interviews, paired interviews, focus group discussions and PhotoVoice. Data were thematically analysed and coded, and themes were extracted. Methodological triangulation enhanced the interpretation. All patients and CTSs and most family members considered community-based DR-TB care to be supportive. Positive aspects were emotional support, trust and dedicated individual care, including enabling practical, financial and social factors. Concerns were related to social and economic problems within the family and fears about infection risks for the family and the CTSs. Community-based DR-TB care was acceptable to patients, family members and CTSs. To reduce family members' fears of TB infection, information and sensitisation within the family and constant follow-up appear crucial.
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Affiliation(s)
- Doris Burtscher
- Médecins Sans Frontières/Ärzte ohne Grenzen, Vienna Evaluation Unit/Anthropology, Wien, Austria
| | | | - Debrah Vambe
- National Tuberculosis Control Program (NTCP), Manzini, Swaziland
| | | | | | | | - Barbara Rusch
- Médecins Sans Frontières, Operational Centre Geneva, Geneva, Switzerland
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13
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Tamirat KS, Andargie G, Babel YA. Factors influencing the length of hospital stay during the intensive phase of multidrug-resistant tuberculosis treatment at Amhara regional state hospitals, Ethiopia: a retrospective follow up study. BMC Public Health 2020; 20:1217. [PMID: 32770982 PMCID: PMC7414745 DOI: 10.1186/s12889-020-09324-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 08/02/2020] [Indexed: 11/10/2022] Open
Abstract
Background The length of hospital stay is the duration of hospitalization, which reflects disease severity and resource utilization indirectly. Generally, tuberculosis is considered an ambulatory disease that could be treated at DOTs clinics; however, admission remains an essential component for patients’ clinical stabilization. Hence, this study aimed to identify factors influencing hospital stay length during the intensive phase of multidrug-resistant tuberculosis treatment. Methods A retrospective follow-up study was conducted at three hospitals, namely the University of Gondar comprehensive specialized, Borumeda, and Debremarkos referral hospitals from September 2010 to December 2016 (n = 432). Data extracted from hospital admission/discharge logbooks and individual patient medical charts. A binary logistic regression analysis was used to identify factors associated with more extended hospital stays during the intensive phase of multidrug-resistant tuberculosis treatment. Result Most patients (93.5%) had a pulmonary form of multidrug-resistant tuberculosis and 26.2% had /TB/HIV co-infections. The median length of hospital stays was 62 (interquartile range from 36 to 100) days. The pulmonary form of tuberculosis (Adjusted odds ratio [AOR], 3.47, 95% confidence interval [CI]; 1.31 to 9.16), bedridden functional status (AOR = 2.88, 95%CI; 1.29 to 6.43), and adverse drug effects (AOR = 2.11, 95%CI; 1.35 to 3.30) were factors associated with extended hospital stays. Conclusion This study revealed that the length of hospital-stay differed significantly between the hospitals. The pulmonary form of tuberculosis decreased functional status at admission and reported adverse drug reactions were determinants of more extended hospital stays. These underscore the importance of early case detection and prompt treatment of adverse drug effects.
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Affiliation(s)
- Koku Sisay Tamirat
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, POB: 196, Gondar, Ethiopia.
| | - Gashaw Andargie
- Department of Health Service Management and Health Economics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, POB: 196, Gondar, Ethiopia
| | - Yaregal Animut Babel
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, POB: 196, Gondar, Ethiopia
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14
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Treatment Adherence Among Persons Receiving Concurrent Multidrug-Resistant Tuberculosis and HIV Treatment in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr 2020; 82:124-130. [PMID: 31513073 DOI: 10.1097/qai.0000000000002120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Success in multidrug-resistant tuberculosis (MDR-TB) and HIV treatment requires high medication adherence despite high pill burdens, frequent adverse events, and long treatment duration, which may jeopardize adherence. We prospectively compared MDR-TB/HIV-coinfected persons to those with MDR-TB alone to determine the impact of concurrent treatment on adherence and outcomes. METHODS We assessed medication adherence monthly using 3-day recall, 30-day recall, and visual analog scale and examined adherence to monthly study visits (months 0-12). We determined the proportion of participants fully adherent (no reported missed doses) to MDR-TB vs. HIV treatment by each measure. We assessed the association of medication and clinic visit adherence with MDR-TB treatment success (cure or completion, 18-24 months) and HIV virologic suppression. RESULTS Among 200 patients with MDR-TB, 63% were women, median age was 33 years, 144 (72%) were HIV-infected, and 81% were receiving antiretroviral therapy (ART) at baseline. Adherence to medications (81%-98% fully adherent across all measures) and clinic visits (80% missed ≤1 visit) was high, irrespective of HIV status. Adherence to ART was significantly higher than to MDR-TB treatment by all self-reported measures (3-day recall: 92% vs. 84%, respectively; P = 0.003). In multivariable analysis, the adjusted risk ratio of unsuccessful MDR-TB treatment increased with every missed visit: 1.50, 2.25, and 3.37 for unsuccessful treatment, for 1, 2, and ≥3 missed visits. CONCLUSIONS Adherence to ART was higher than to MDR-TB treatment among persons with MDR-TB/HIV coinfection. Missed clinic visits may be a simple measure for identifying patients at risk of unsuccessful MDR-TB treatment outcome.
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15
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Vanleeuw L, Atkins S, Zembe-Mkabile W, Loveday M. Provider perspectives of the introduction and implementation of care for drug-resistant tuberculosis patients in district-level facilities in South Africa: a qualitative study. BMJ Open 2020; 10:e032591. [PMID: 32019816 PMCID: PMC7044892 DOI: 10.1136/bmjopen-2019-032591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Drug-resistant tuberculosis (DR-TB) is a growing concern in many low-income and middle-income countries. Facing rising numbers of DR-TB patients, South Africa (SA) introduced a decentralised model of care for DR-TB in 2011. We aimed to document the introduction and implementation of the new models of care for patients with DR-TB in four provinces (Northern Cape, KwaZulu-Natal, Eastern Cape and Gauteng) in 2015 using mixed methods, including interviews, register reviews and clinical audits. This paper reports on the qualitative component of the study. DESIGN This is a qualitative interview study. SETTING Data were collected in 22 decentralised DR-TB sites, primary healthcare facilities and district hospitals and one provincial central DR-TB hospital. PARTICIPANTS 58 healthcare workers (HCWs), facility staff and provincial and district TB coordinators were included in qualitative interviews. RESULTS HCWs felt that the introduction of DR-TB care in their facility came with little warning or engagement, creating fear and anxiety. They expressed a need for support from the district and province to guide them through the changes but this support was often lacking. In addition, many respondents expressed feeling isolated and not supported by other healthcare providers which they feel impacts on the quality of the care they provide. CONCLUSION Introduction of a new service such as DR-TB care can be difficult and does not always result in the intended outcomes. Improved engagement with front-line providers and addressing the fear and anxiety that may be raised by changes in daily practices should be addressed to ensure successful implementation and prevent negative consequences that can hamper quality of care for patients. Attention should be paid to how the decentralised DR-TB unit can be supported by district management and other healthcare providers.
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Affiliation(s)
- Lieve Vanleeuw
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Salla Atkins
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Wanga Zembe-Mkabile
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Marian Loveday
- Health Systems Research Unit, South African Medical Research Council, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
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16
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Sinha P, Shenoi SV, Friedland GH. Opportunities for community health workers to contribute to global efforts to end tuberculosis. Glob Public Health 2019; 15:474-484. [PMID: 31516079 DOI: 10.1080/17441692.2019.1663361] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Tuberculosis (TB) has emerged as the leading infectious cause of death globally. New paradigms are needed to reduce TB rates and mortality. Programs harnessing the potential of community health workers (CHWs) to enhance TB prevention and care have shown great promise. In this perspective article, we review the history of CHW-based efforts to prevent and treat TB, present evidence illustrating the effectiveness of CHWs across the entire cascade of TB care, and outline additional opportunities for CHWs to address challenges particular to the TB pandemic. Despite many promising studies, knowledge gaps persist and we suggest an agenda for future research on the role of CHWs in TB prevention and care.
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Affiliation(s)
- Pranay Sinha
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA
| | - Sheela V Shenoi
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, AIDS Program, New Haven, CT, USA
| | - Gerald H Friedland
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, AIDS Program, New Haven, CT, USA
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17
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Kerschberger B, Telnov A, Yano N, Cox H, Zabsonre I, Kabore SM, Vambe D, Ngwenya S, Rusch B, Tombo ML, Ciglenecki I. Successful expansion of community-based drug-resistant TB care in rural Eswatini - a retrospective cohort study. Trop Med Int Health 2019; 24:1243-1258. [PMID: 31390108 PMCID: PMC6851784 DOI: 10.1111/tmi.13299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives Provision of drug‐resistant tuberculosis (DR‐TB) treatment is scarce in resource‐limited settings. We assessed the feasibility of ambulatory DR‐TB care for treatment expansion in rural Eswatini. Methods Retrospective patient‐level data were used to evaluate ambulatory DR‐TB treatment provision in rural Shiselweni (Eswatini), from 2008 to 2016. DR‐TB care was either clinic‐based led by nurses or community‐based at the patient's home with involvement of community treatment supporters for provision of treatment to patients with difficulties in accessing facilities. We describe programmatic outcomes and used multivariate flexible parametric survival models to assess time to adverse outcomes. Both care models were costed in supplementary analyses. Results Of 698 patients initiated on DR‐TB treatment, 57% were women and 84% were HIV‐positive. Treatment initiations increased from 27 in 2008 to 127 in 2011 and decreased thereafter to 51 in 2016. Proportionally, community‐based care increased from 19% in 2009 to 77% in 2016. Treatment success was higher for community‐based care (79%) than clinic‐based care (68%, P = 0.002). After adjustment for covariate factors among adults (n = 552), the risk of adverse outcomes (death, loss to follow‐up, treatment failure) in community‐based care was reduced by 41% (adjusted hazard ratio 0.59, 95% CI: 0.39–0.91). Findings were supported by sensitivity analyses. The care provider's per‐patient costs for community‐based (USD13 345) and clinic‐based (USD12 990) care were similar. Conclusions Ambulatory treatment outcomes were good, and community‐based care achieved better treatment outcomes than clinic‐based care at comparable costs. Contextualised DR‐TB care programmes are feasible and can support treatment expansion in rural settings.
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Affiliation(s)
| | - Alex Telnov
- Medecins Sans Frontieres (Operational Centre Geneva), Geneva, Switzerland
| | - Nanako Yano
- Clinton Health Access Initiative, Mbabane, Eswatini
| | - Helen Cox
- Institute of Infectious Diseases and Molecular Medicine, Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa
| | - Inoussa Zabsonre
- Medecins Sans Frontieres (Operational Centre Geneva), Mbabane, Eswatini
| | | | - Debrah Vambe
- National TB Control Programme, Manzini, Eswatini
| | | | - Barbara Rusch
- Medecins Sans Frontieres (Operational Centre Geneva), Geneva, Switzerland
| | - Marie Luce Tombo
- Medecins Sans Frontieres (Operational Centre Geneva), Mbabane, Eswatini
| | - Iza Ciglenecki
- Medecins Sans Frontieres (Operational Centre Geneva), Geneva, Switzerland
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18
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Agins BD, Ikeda DJ, Reid MJA, Goosby E, Pai M, Cattamanchi A. Improving the cascade of global tuberculosis care: moving from the "what" to the "how" of quality improvement. THE LANCET. INFECTIOUS DISEASES 2019; 19:e437-e443. [PMID: 31447305 DOI: 10.1016/s1473-3099(19)30420-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/29/2019] [Accepted: 06/12/2019] [Indexed: 12/27/2022]
Abstract
Tuberculosis is preventable, treatable, and curable, yet it has the highest mortality rate of infectious diseases worldwide. Over the past decade, services to prevent, screen, diagnose, and treat tuberculosis have been developed and scaled up globally, but progress to end the disease as a public health threat has been slow, particularly in low-income and middle-income countries. In these settings, low-quality tuberculosis prevention, diagnostic, and treatment services frustrate efforts to translate use of existing tools, approaches, and treatment regimens into improved individual and public health outcomes. Increasingly sophisticated methods have been used to identify gaps in quality of tuberculosis care, but inadequate work has been done to apply these findings to activities that generate population-level improvements. In this Personal View, we contend that shifting the focus from the "what" to the "how" of quality improvement will require National Tuberculosis Programmes to change the way they organise, use data, implement, and respond to the needs and preferences of people with tuberculosis and at-risk communities.
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Affiliation(s)
- Bruce D Agins
- HEALTHQUAL, Institute for Global Health Sciences, University of California, San Francisco, CA, USA; Division of Global Epidemiology, University of California, San Francisco, CA, USA; Institute for Implementation Science in Population Health, City University of New York, NY, USA.
| | - Daniel J Ikeda
- HEALTHQUAL, Institute for Global Health Sciences, University of California, San Francisco, CA, USA; Harvard Medical School, Boston, MA, USA
| | - Michael J A Reid
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA, USA
| | - Eric Goosby
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Canada
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
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19
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van Rensburg C, Berhanu R, Hirasen K, Evans D, Rosen S, Long L. Cost outcome analysis of decentralized care for drug-resistant tuberculosis in Johannesburg, South Africa. PLoS One 2019; 14:e0217820. [PMID: 31170207 PMCID: PMC6553851 DOI: 10.1371/journal.pone.0217820] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 05/21/2019] [Indexed: 11/19/2022] Open
Abstract
Background Drug resistant-tuberculosis is a growing burden on the South African health care budget. In response the National Department of Health implemented two important strategies in 2011; universal access to drug-sensitivity testing for rifampicin with Xpert MTB/RIF as the first-line diagnostic test for TB; and decentralization of treatment for RR/MDR-TB to improve access and reduce costs of treatment. Objective Estimate the costs by treatment outcome of decentralized care for rifampicin and multi-drug resistant tuberculosis under routine conditions. The study was set at an outpatient drug resistant-tuberculosis treatment facility at a public academic hospital in Johannesburg, South Africa. During the study period 18–24 month long course treatment was offered for rifampicin-resistant and multi-drug-resistant tuberculosis. Methods Data are from a prospective observational cohort study. Costs of treatment were estimated from the provider perspective using bottom-up micro-costing. Costs were estimated as patient-level resource use multiplied by the unit cost of the resource. Clinic visits, drugs, laboratory tests, and total days hospitalized were collected from patients’ medical records. Staff time was estimated through a time and motion study. A successful treatment outcome was defined as cure or completion of the regimen. Results We enrolled 124 patients with 52% having a successful outcome. The average total cost/patient for all patients was $3,430 and $4,530 for successfully treated patients. The largest contributors to total cost across all outcomes were drugs (43%) and staff (28%). The average cost to achieve a successful outcome including all patients who started treatment (“production cost”) in the cohort is $6,684. Conclusions Decentralized, outpatient RR/MDR-TB care under South Africa’s 2011 strategy costs 74% less per patient than the previous strategy of inpatient care. The treatment cost of RR/MDR-TB is primarily driven by drug and staff costs, which are in turn dependant on treatment length.
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Affiliation(s)
- Craig van Rensburg
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Rebecca Berhanu
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, United States of America
| | - Kamban Hirasen
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, United States of America
| | - Lawrence Long
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, United States of America
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20
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Ballestero JGDA, de Lima MCRAD, Garcia JM, Gonzales RIC, Sicsú AN, Mitano F, Palha PF. [Control and management strategies in multidrug-resistant tuberculosis: literature reviewEstrategias de control y atención de la tuberculosis multirresistente: una revisión de la literatura]. Rev Panam Salud Publica 2019; 43:e20. [PMID: 31093244 PMCID: PMC6459353 DOI: 10.26633/rpsp.2019.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/30/2018] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To identify control and patient management strategies for multidrug-resistant tuberculosis (MDR-TB). METHODS An integrative review of the literature was performed through research in three health databases (LILACS, PubMed and CINAHL) and one multidisciplinary database (Scopus). Original articles published in English, Spanish or Portuguese, from 2006 to 2016, describing strategies to implement MDR-TB patient care, were included. The information collected was organized according to the strategies identified by the investigators, which were grouped into theme categories. RESULTS Based on a sample of 13 articles, four categories were identified: a) DOTS-plus: reorganization of health services, improvement of local structures, standardization of professional protocols and behaviors, provision of directly observed treatment; b) service decentralization: bringing health professionals closer to patients, especially in areas with high disease burden; c) use of communication tools: software and telephone calls that allowed consultations with specialists and/or optimization of care within multiprofessional teams; d) social protection of patients: establishment of mechanisms to provide emotional, social and/or economic support to patients under treatment, strengthening adherence to drug therapy. CONCLUSIONS Several strategies were identified beyond pharmacological measures, supporting the idea that the control of MDR-TB requires mechanisms that allow comprehensive care, consistent with the peculiarities and potentialities of the different scenarios where the disease occurs.
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Affiliation(s)
- Jaqueline Garcia de Almeida Ballestero
- Escola de Enfermagem de Ribeirão PretoEscola de Enfermagem de Ribeirão PretoUniversidade de São Paulo (USP)Ribeirão PretoSPBrasilUniversidade de São Paulo (USP), Escola de Enfermagem de Ribeirão Preto, Ribeirão Preto (SP), Brasil.
| | - Mônica Cristina Ribeiro Alexandre d´Auria de Lima
- Escola de Enfermagem de Ribeirão PretoEscola de Enfermagem de Ribeirão PretoUniversidade de São Paulo (USP)Ribeirão PretoSPBrasilUniversidade de São Paulo (USP), Escola de Enfermagem de Ribeirão Preto, Ribeirão Preto (SP), Brasil.
| | - Juliana Masini Garcia
- Escola de Enfermagem de Ribeirão PretoEscola de Enfermagem de Ribeirão PretoUniversidade de São Paulo (USP)Ribeirão PretoSPBrasilUniversidade de São Paulo (USP), Escola de Enfermagem de Ribeirão Preto, Ribeirão Preto (SP), Brasil.
| | - Roxana Isabel Cardozo Gonzales
- Faculdade de EnfermagemFaculdade de EnfermagemUniversidade Federal de Pelotas (UFPel)PelotasRSBrasilUniversidade Federal de Pelotas (UFPel), Faculdade de Enfermagem, Pelotas (RS), Brasil.
| | - Amélia Nunes Sicsú
- Escola Superior de Ciências da SaúdeEscola Superior de Ciências da SaúdeUniversidade do Estado do AmazonasManausAMBrasilUniversidade do Estado do Amazonas, Escola Superior de Ciências da Saúde, Manaus (AM), Brasil.
| | - Fernando Mitano
- Faculdade de Ciências de SaúdeFaculdade de Ciências de SaúdeUniversidade LúrioNampulaMoçambiqueUniversidade Lúrio, Faculdade de Ciências de Saúde, Nampula, Moçambique.
| | - Pedro Fredemir Palha
- Escola de Enfermagem de Ribeirão PretoEscola de Enfermagem de Ribeirão PretoUniversidade de São Paulo (USP)Ribeirão PretoSPBrasilUniversidade de São Paulo (USP), Escola de Enfermagem de Ribeirão Preto, Ribeirão Preto (SP), Brasil.
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Law S, Daftary A, O'Donnell M, Padayatchi N, Calzavara L, Menzies D. Interventions to improve retention-in-care and treatment adherence among patients with drug-resistant tuberculosis: a systematic review. Eur Respir J 2019; 53:13993003.01030-2018. [PMID: 30309972 DOI: 10.1183/13993003.01030-2018] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/20/2018] [Indexed: 11/05/2022]
Abstract
The global loss to follow-up (LTFU) rate among drug-resistant tuberculosis (DR-TB) patients remains high at 15%. We conducted a systematic review to explore interventions to reduce LTFU during DR-TB treatment.We searched for studies published between January 2000 and December 2017 that provided any form of psychosocial or material support for patients with DR-TB. We estimated point estimates and 95% confidence intervals of the proportion LTFU. We performed subgroup analyses and pooled estimates using an exact binomial likelihood approach.We included 35 DR-TB cohorts from 25 studies, with a pooled proportion LTFU of 17 (12-23)%. Cohorts that received any form of psychosocial or material support had lower LTFU rates than those that received standard care. Psychosocial support throughout treatment, via counselling sessions or home visits, was associated with lower LTFU rates compared to when support was provided through a limited number of visits or not at all.Our review suggests that psychosocial support should be provided throughout DR-TB treatment in order to reduce treatment LTFU. Future studies should explore the potential of providing self-administered therapy complemented with psychosocial support during the continuation phase.
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Affiliation(s)
- Stephanie Law
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Amrita Daftary
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,McGill International TB Centre, McGill University, Montreal, QC, Canada.,CAPRISA-MRC TB-HIV Pathogenesis and Treatment Unit, Durban, South Africa
| | - Max O'Donnell
- CAPRISA-MRC TB-HIV Pathogenesis and Treatment Unit, Durban, South Africa.,Division of Pulmonary, Allergy and Critical Care Medicine, and Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Nesri Padayatchi
- CAPRISA-MRC TB-HIV Pathogenesis and Treatment Unit, Durban, South Africa
| | - Liviana Calzavara
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Dick Menzies
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,McGill International TB Centre, McGill University, Montreal, QC, Canada
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22
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Watermeyer J, Penn C. Community perspectives on tuberculosis care in rural South Africa. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:182-190. [PMID: 30159955 DOI: 10.1111/hsc.12637] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/22/2018] [Accepted: 07/29/2018] [Indexed: 06/08/2023]
Abstract
Patient nonadherence to tuberculosis (TB) treatment is an ongoing challenge, particularly since the advent of drug-resistant TB and complications posed by HIV/AIDS. Some solutions may lie in understanding patient and community perspectives about barriers to TB care and treatment adherence. Using a qualitative framework, we explored community perceptions and beliefs about TB and perceived facilitators and barriers to care in a rural South African community affected by TB. We were particularly interested in capturing cross-cutting themes and the "merged voices" of participants. Interviews were conducted in 2013 and 2014 with 43 participants, including home-based care workers, clinic staff, patients living with TB and community members in and around a primary healthcare clinic. The data were analysed using principles of thematic analysis. The study reveals the complex interplay between contextual factors and community understandings of the disease. Cultural beliefs about causality and treatment-seeking paths were often mentioned in conjunction with biomedical views. There was a strong interface between TB and HIV in this community, and knowledge of TB was often confused with HIV. HIV-related stigma has been extended to those living with TB. The impact of poverty on treatment adherence was a particularly important theme. Other themes related to the role of the clinic in the community. Our study highlights the socioeconomic vulnerability of this community and the fragility of existing care systems. The findings reinforce the need for a community-centred approach to TB care that takes cognisance of lifeworld issues. We discuss some implications of this study for practice and policy.
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Affiliation(s)
- Jennifer Watermeyer
- Health Communication Research Unit, School of Human and Community Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Claire Penn
- Health Communication Research Unit, School of Human and Community Development, University of the Witwatersrand, Johannesburg, South Africa
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23
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Woya AA, Tekile AK, Basha GW. Spatial Frailty Survival Model for Multidrug-Resistant Tuberculosis Mortality in Amhara Region, Ethiopia. Tuberc Res Treat 2019; 2019:8742363. [PMID: 30693105 PMCID: PMC6332868 DOI: 10.1155/2019/8742363] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis (TB), a disease caused by Mycobacterium tuberculosis (MTB), is the main cause of death. It disproportionally affects those living in the different regions of countries and within the region. The aim of this study was to examine spatial variation of mortality and the risk factor of death on multidrug-resistant tuberculosis patients treated in different MDR-TB hospitals of Amhara region. The data for this study was used from multidrug-resistant tuberculosis patients' record charts and analyzed using STATA software. The result of this study shows that 61 (29.47%) of the patients died, and the rest, 146 (70.53%), of the patients were censored at the time of the study. Out of 207 MDR-TB, 146 (70.53%) were males and 61 (29.5%) were females. This study revealed that there was no heterogeneity for death in patients treated in different hospitals. Older patients, therapeutic delay, alcohol use, any clinical complication previously not treated, HIV coinfection, and presence of any chronic disease were the risk factors that influenced the death of multidrug-resistant tuberculosis patients.
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Affiliation(s)
- Ashenafi Abate Woya
- Department of Statistics, College of Science, Bahir Dar University, P.O. Box 79, Bahir Dar, Ethiopia
| | - Abay Kassa Tekile
- Department of Statistics, College of Science, Bahir Dar University, P.O. Box 79, Bahir Dar, Ethiopia
| | - Garoma Wakjira Basha
- Department of Statistics, College of Science, Bahir Dar University, P.O. Box 79, Bahir Dar, Ethiopia
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24
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Campoy LT, Arakawa T, Andrade RLDP, Ruffino-Netto A, Monroe AA, Arcêncio RA. QUALITY AND MANAGEMENT OF CARE TO TUBERCULOSIS/HIV COINFECTION IN THE STATE OF SÃO PAULO, BRAZIL. TEXTO & CONTEXTO ENFERMAGEM 2019. [DOI: 10.1590/1980-265x-tce-2018-0166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: to analyze the quality and management of care to tuberculosis/HIV coinfection in the state of São Paulo, Brazil. Methods: a descriptive study involving municipalities having at least five cases of tuberculosis/HIV coinfection in the Brazilian state of São Paulo notified in the tuberculosis notification system. To analyze the quality and management of care to tuberculosis/HIV coinfection, indicators were designed, based on tuberculosis evaluability assessment studies, and validated in Brazil. The municipalities were grouped according to their care quality and then submitted to multiple correspondence analysis. Results: the study formed a group with 18 municipalities (42.86%) with satisfactory care and management quality, and another group with 24 municipalities (57.14%) with a quality characterized as unsatisfactory. In the municipalities that showed a satisfactory result, the investigation identified a low proportion of tuberculosis/HIV coinfection, a low AIDS incidence rate, intermediate population size, and high coverage of the Community Health Workers’ Program and Family Health Strategy. The municipalities with unsatisfactory quality had a high proportion of tuberculosis/HIV coinfection and a high AIDS incidence rate. Conclusion: the study reveals the defining characteristics of quality and management of care to tuberculosis/HIV coinfection as chronic conditions, bringing relevant elements regarding the mobilization of resources and investments in the municipalities where these are necessary. Additionally, the investigation shows that health results are critical where care quality is unsatisfactory, pointing out the need for reorganizing care and the management of actions involving control of tuberculosis/HIV coinfection in these contexts.
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25
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Ferreira KR, Orlandi GM, Silva TCD, Bertolozzi MR, França FODS, Bender A. Representations on adherence to the treatment of Multidrug-Resistant Tuberculosis. Rev Esc Enferm USP 2018; 52:e03412. [PMID: 30569960 DOI: 10.1590/s1980-220x2018010303412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/31/2018] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To identify representations regarding adherence to the treatment of multidrug-resistant tuberculosis from the perspective of patients who were discharged upon being cured. METHOD A qualitative study with patients who completed the drug treatment for multidrug-resistant tuberculosis in São Paulo. Social Determination was used to interpret the health-disease process, and the testimonies were analyzed according to dialectical hermeneutics and the discourse analysis technique. RESULTS Twenty-one patients were interviewed. The majority (80.9%) were men, in the productive age group (90.4%) and on sick leave or unemployed (57.2%) during the treatment. Based on the testimonies, three categories associated with adherence to treatment emerged: the desire to live, support for the development of treatment and care provided by the health services. CONCLUSION For the study sample, adherence to the treatment of multidrug-resistant tuberculosis was related to having a life project and support from the family and health professionals. Free treatment is fundamental for adherence, given the fragilities arising from the social insertion of people affected by the disease. Therefore, special attention is required from the health services to understand patient needs.
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Affiliation(s)
| | - Giovanna Mariah Orlandi
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem em Saúde Coletiva, São Paulo, SP, Brazil
| | - Talina Carla da Silva
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem em Saúde Coletiva, São Paulo, SP, Brazil
| | - Maria Rita Bertolozzi
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem em Saúde Coletiva, São Paulo, SP, Brazil
| | | | - Amy Bender
- University of Toronto, Faculty of Nursing, Toronto, Ontário, Canada
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26
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Verdecchia M, Keus K, Blankley S, Vambe D, Ssonko C, Piening T, Casas EC. Model of care and risk factors for poor outcomes in patients on multi-drug resistant tuberculosis treatment at two facilities in eSwatini (formerly Swaziland), 2011-2013. PLoS One 2018; 13:e0205601. [PMID: 30332452 PMCID: PMC6192624 DOI: 10.1371/journal.pone.0205601] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/27/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction Since 2011 Médecins sans Frontières together with the eSwatini Ministry of Health have been managing patients with multi-drug resistant tuberculosis (MDR-TB) at Matsapha and Mankayane in Manzini region. This analysis describes the model of care and outcomes of patients receiving a 20 months MDR-TB treatment regimen between 2011 and 2013. Method We conducted a retrospective observational cohort study of MDR-TB patients enrolled for treatment between May 2011 and December 2013. An extensive package of psychological care and socio-economic incentives were provided including psychological support, paid treatment supporters, transport fees and a monthly food package. Baseline demographic details and treatment outcomes were recorded and for HIV positive patient’s univariate analysis as well as a cox regression hazard model were undertaken to assess risk factors for unfavorable outcomes. Results From the 174 patients enrolled, 156 (89.7%) were HIV co-infected, 102 (58.6%) were female, median age 33 years old (IQR: 28–42), 55 (31.6%) had a BMI less than 18 and 86 (49.4%) had not been previously treated for any form of TB. Overall cohort outcomes revealed a 75.3% treatment success rate, 21.3% mortality rate, 0.6% failure and 0.6% lost to follow-up rate. In the adjusted multivariate analysis, low BMI and low CD4 count at treatment initiation were associated with an increased risk of unfavorable outcome. Conclusions A model of care that included psychosocial support and patient’s enablers led to a high level of treatment success with a very low lost to follow up rate. Limiting the overall treatment success was a high mortality rate which was associated with advanced HIV and a low BMI at presentation. These factors will need to be addressed in order to improve upon the overall treatment success rate in future.
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Affiliation(s)
- M. Verdecchia
- Medecins Sans Frontieres, OCA-Swaziland, Lomalanga building, Manzini, eSwatini
- * E-mail:
| | - K. Keus
- Medecins Sans Frontieres, OCA-Swaziland, Lomalanga building, Manzini, eSwatini
| | - S. Blankley
- Medecins Sans Frontieres, OCA-Swaziland, Lomalanga building, Manzini, eSwatini
| | - D. Vambe
- National TB control programme, Manzini, eSwatini
| | - C. Ssonko
- Medecins Sans Frontieres, The Manson Unit, Lower Ground Floor, Chancery Exchange, London, United Kingdom
| | - T. Piening
- Medecins Sans Frontieres, OCA-Berlin, Berlin, Germany
| | - E. C. Casas
- Medecins Sans Frontieres, Southern Africa Medical Unit, Observatory, Cape Town, South Africa
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Sam S, Shapiro AE, Sok T, Khann S, So R, Khem S, Chhun S, Noun S, Koy B, Sayouen PC, Im Sin C, Bunsieth H, Mao TE, Goldfeld AE. Initiation, scale-up and outcomes of the Cambodian National MDR-TB programme 2006-2016: hospital and community-based treatment through an NGO-NTP partnership. BMJ Open Respir Res 2018; 5:e000256. [PMID: 29955361 PMCID: PMC6018896 DOI: 10.1136/bmjresp-2017-000256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 02/21/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction Prolonged inpatient multidrug-resistant tuberculosis (MDR-TB) treatment for all patients is not sustainable for high-burden settings, but there is limited information on community-based treatment programme outcomes for MDR-TB. Methods The Cambodian Health Committee, a non-governmental organisation (NGO), launched the Cambodian MDR-TB programme in 2006 in cooperation with the National Tuberculosis Program (NTP) including a community-based treatment option as a key programme component. The programme was transferred to NTP oversight in 2011 with NGO clinical management continuing. Patients electing to receive home-based treatment were followed by a dedicated adherence supporter and a multidisciplinary outpatient team of nurses, physicians and community health workers. Patients hospitalised for >1 month of treatment (hospital based) received similar management after discharge. All patients received a standardised second-line MDR-TB regimen and were provided nutritional and adherence support. Outcomes were reviewed for patients completing 24 months of treatment and predictors of treatment success were evaluated using logistic regression. Results Of 582 patients with MDR-TB who initiated treatment between September 2006 and June 2016, 20% were HIV coinfected, 288 (49%) initiated community-based treatment and 294 (51%) received hospital-based treatment. Of 486 patients with outcomes available, 364 (75%) were cured, 10 (2%) completed, 28 (6%) were lost to follow-up, 3 (0.6%) failed and 77 (16%) died. There was no difference between treatment success in community versus hospital-based groups (adjusted OR (aOR) 1.0, p=0.99). HIV infection, older age and body mass index <16 were strongly associated with decreased treatment success (aOR 0.33, p<0.001; aOR 0.40, p<0.001; aOR 0.40; p<0.001). Conclusions Cambodia’s NGO–NTP partnership successfully developed and scaled up a model MDR-TB treatment programme. The first large-scale MDR-TB programme in Asia with a significant community-based component, the programme achieved equally high treatment success in patients with community-based compared with hospital-based initiation of MDR treatment.
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Affiliation(s)
- Sophan Sam
- Cambodian Health Committee, Phnom Penh, Cambodia
| | - Adrienne E Shapiro
- Cambodian Health Committee, Phnom Penh, Cambodia.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Thim Sok
- Cambodian Health Committee, Phnom Penh, Cambodia
| | - Sokhan Khann
- Cambodian Health Committee, Phnom Penh, Cambodia.,WHO-Cambodia, Phnom Penh, Cambodia
| | - Rassi So
- Cambodian Health Committee, Phnom Penh, Cambodia
| | - Sopheap Khem
- Cambodian Health Committee, Phnom Penh, Cambodia
| | - Sokhem Chhun
- Cambodian Health Committee, Phnom Penh, Cambodia
| | - Sarith Noun
- Cambodian Health Committee, Phnom Penh, Cambodia
| | - Bonamy Koy
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Prum Chhom Sayouen
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Chun Im Sin
- Khmer Soviet Friendship Hospital, Phnom Penh, Cambodia
| | | | - Tan Eang Mao
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Anne E Goldfeld
- Cambodian Health Committee, Phnom Penh, Cambodia.,Program in Cellular and Molecular Medicine, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts, USA
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28
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Masquillier C, Wouters E, Sommerland N, Rau A, Engelbrecht M, Kigozi G, van Rensburg AJ. Fighting stigma, promoting care: a study on the use of occupationally-based HIV services in the Free State Province of South Africa. AIDS Care 2018; 30:16-23. [PMID: 29848050 DOI: 10.1080/09540121.2018.1468010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Fear of breaches in confidentiality and HIV-related stigma in the workplace have been shown to be primary concerns and potential barriers to uptake of HIV testing and treatment by health care workers (HCWs) at the Occupational Health Unit (OHU). In a context of human resource shortages, it is essential to investigate potential ways of reducing HIV-related stigma and promoting confidentially in the workplace. Using Structural Equation Modelling (SEM), baseline data of the "HIV and TB Stigma among Health Care Workers Study" (HaTSaH Study) for 818 respondents has been analysed to investigate (1) whether bottom-up stigma-reduction activities already occur; and (2) whether such grassroots actions can reduce the fear of breaches in confidentiality and HIV-related stigma - and thus indirectly stimulate the uptake of HIV services at the OHU. Results (aim 1) illustrate the occurrence of existing activities aiming to reduce HIV-related stigma, such as HCWs giving extra support to HIV positive co-workers and educating co-workers who stigmatise HIV. Furthermore, results of the SEM analysis (aim 2) show that the Fighting-stigma factor has a significant negative effect on HIV-related stigma and a significant positive effect on Confidentiality. Results show that the latent fighting-stigma factor has a significant positive total indirect effect on the use of HIV testing, CD4 cell count and HIV-treatment at the OHU. The findings reveal that the fear of breaches in confidentiality and HIV-related stigma can be potential barriers to the uptake of occupationally-based HIV services. However, results also show that a bottom-up climate of fighting HIV-related stigma can stimulate confidentiality in the workplace and diminish the negative effect of HIV-related stigma - resulting in an overall positive effect on the reported willingness to access occupationally-based HIV services.
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Affiliation(s)
- Caroline Masquillier
- a Department of Sociology and Centre for Longitudinal and Life Course Studies , University of Antwerp , Antwerp , Belgium
| | - Edwin Wouters
- a Department of Sociology and Centre for Longitudinal and Life Course Studies , University of Antwerp , Antwerp , Belgium.,b Centre for Health Systems Research and Development , University of the Free State , Bloemfontein , South Africa
| | - Nina Sommerland
- a Department of Sociology and Centre for Longitudinal and Life Course Studies , University of Antwerp , Antwerp , Belgium
| | - Asta Rau
- b Centre for Health Systems Research and Development , University of the Free State , Bloemfontein , South Africa
| | - Michelle Engelbrecht
- b Centre for Health Systems Research and Development , University of the Free State , Bloemfontein , South Africa
| | - Gladys Kigozi
- b Centre for Health Systems Research and Development , University of the Free State , Bloemfontein , South Africa
| | - Andre Janse van Rensburg
- b Centre for Health Systems Research and Development , University of the Free State , Bloemfontein , South Africa
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29
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Lin Y, Enarson DA, Du J, Dlodlo RA, Chiang CY, Rusen ID. Risk factors for unfavourable treatment outcome among new smear-positive pulmonary tuberculosis cases in China. Public Health Action 2017; 7:299-303. [PMID: 29584792 DOI: 10.5588/pha.17.0056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Accepted: 08/25/2017] [Indexed: 11/10/2022] Open
Abstract
Setting: Three projects of the Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB. Objectives: To assess unfavourable treatment outcomes (UTOs), including failure, died, loss to follow-up (LTFU), transferred out and unknown outcome, and to identify risk factors associated with UTOs. Design: This was a cross-sectional study using routine programme data. Results: Of 30 277 new smear-positive tuberculosis (TB) patients, 4261 (14.1%) had UTOs: 2048 (6.8%) LTFU, 1418 (4.7%) transferred out, 390 (1.3%) died, 340 (1.1%) failed and 65 (0.2%) had an unknown outcome. Risk factors for LTFU (including LTFU, transfer out and unknown outcome) were residing in Anhui, age > 55 years, service delay > 10 days, patient delay < 30 days, directly observed treatment (DOT) provided by a family member or others and unknown DOT provider. The outcome of 'died' was associated with residing in Shaanxi, age > 55 years, male sex, patient delay > 30 days and unknown DOT provider. 'Failed' was associated with having unlimited access to health services, patient delay of >30 days and unknown DOT provider. Conclusion: This study highlights the predominance of lost patients among UTOs. Patients with family members or other non-medical DOT providers or unknown DOT providers had a high risk of a UTO. There is an urgent need to address these service-related factors.
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Affiliation(s)
- Y Lin
- International Union Against Tuberculosis and Lung Disease (The Union), Beijing, China.,The Union, Paris, France
| | | | - J Du
- Beijing Chest Hospital, Capital Medical University, Beijing, China.,Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
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30
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Kapwata T, Morris N, Campbell A, Mthiyane T, Mpangase P, Nelson KN, Allana S, Brust JCM, Moodley P, Mlisana K, Gandhi NR, Shah NS. Spatial distribution of extensively drug-resistant tuberculosis (XDR TB) patients in KwaZulu-Natal, South Africa. PLoS One 2017; 12:e0181797. [PMID: 29028800 PMCID: PMC5640212 DOI: 10.1371/journal.pone.0181797] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/09/2017] [Indexed: 11/18/2022] Open
Abstract
Background KwaZulu-Natal province, South Africa, has among the highest burden of XDR TB worldwide with the majority of cases occurring due to transmission. Poor access to health facilities can be a barrier to timely diagnosis and treatment of TB, which can contribute to ongoing transmission. We sought to determine the geographic distribution of XDR TB patients and proximity to health facilities in KwaZulu-Natal. Methods We recruited adults and children with XDR TB diagnosed in KwaZulu-Natal. We calculated distance and time from participants’ home to the closest hospital or clinic, as well as to the actual facility that diagnosed XDR TB, using tools within ArcGIS Network analyst. Speed of travel was assigned to road classes based on Department of Transport regulations. Results were compared to guidelines for the provision of social facilities in South Africa: 5km to a clinic and 30km to a hospital. Results During 2011–2014, 1027 new XDR TB cases were diagnosed throughout all 11 districts of KwaZulu-Natal, of whom 404 (39%) were enrolled and had geospatial data collected. Participants would have had to travel a mean distance of 2.9 km (CI 95%: 1.8–4.1) to the nearest clinic and 17.6 km (CI 95%: 11.4–23.8) to the nearest hospital. Actual distances that participants travelled to the health facility that diagnosed XDR TB ranged from <10 km (n = 143, 36%) to >50 km (n = 109, 27%), with a mean of 69 km. The majority (77%) of participants travelled farther than the recommended distance to a clinic (5 km) and 39% travelled farther than the recommended distance to a hospital (30 km). Nearly half (46%) of participants were diagnosed at a health facility in eThekwini district, of whom, 36% resided outside the Durban metropolitan area. Conclusions XDR TB cases are widely distributed throughout KwaZulu-Natal province with a denser focus in eThekwini district. Patients travelled long distances to the health facility where they were diagnosed with XDR TB, suggesting a potential role for migration or transportation in the XDR TB epidemic.
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Affiliation(s)
- Thandi Kapwata
- Environment and Health Research Unit, South African Medical Research Council, Johannesburg, South Africa
| | - Natashia Morris
- Biostatistics Unit, South African Medical Research Council, Durban, KwaZulu-Natal, South Africa
| | - Angela Campbell
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Thuli Mthiyane
- Departments of Medical Microbiology and Virology, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Primrose Mpangase
- Departments of Medical Microbiology and Virology, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Kristin N. Nelson
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Salim Allana
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - James C. M. Brust
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States of America
| | - Pravi Moodley
- Departments of Medical Microbiology and Virology, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Koleka Mlisana
- Departments of Medical Microbiology and Virology, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Neel R. Gandhi
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Division of Infectious Diseases, Emory School of Medicine, Atlanta, Georgia, United States of America
- * E-mail:
| | - N. Sarita Shah
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Global Tuberculosis Branch, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Baghaei P, Tabarsi P, Moniri A, Marjani M, Farnia P, Jabbehdari S, Velayati AA. Distribution scheme of antituberculosis drug resistance among HIV patients in a referral centre over 10 years. J Glob Antimicrob Resist 2017; 11:116-119. [PMID: 28739225 DOI: 10.1016/j.jgar.2017.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 04/18/2017] [Accepted: 06/29/2017] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Antituberculosis drug resistance is increasing among tuberculosis (TB) patients globally, particularly in those who are human immunodeficiency virus (HIV)-positive. The aim of this study was to determine the pattern of anti-TB drug resistance in these patients in an effort to improve successful treatment outcomes with a proper regimen. METHODS A cross-sectional study was conducted on adult TB/HIV co-infected patients from 2005-2015. The pattern of anti-TB drug resistance was evaluated among HIV-positive patients with and without a history of TB treatment. Categorisation was made as follows: isoniazid (INH)-resistant; rifampicin (RIF)-resistant; or multidrug-resistant (MDR). RESULTS A total of 52 patients were enrolled in this study (median age 38 years). Among the 52 patients, 18 (34.6%) were MDR-TB patients and the rest were monoresistant TB (resistant either to INH or RIF). INH resistance was the most common resistance pattern (36.5%) noted among patients and was significantly associated with new TB cases (69% vs. 31%; P=0.01). During TB treatment, 3/48 patients (6.3%) failed treatment and 11/48 (22.9%) died. Patients with MDR-TB were more likely to die during treatment (44.4% vs. 10%; P=0.011). CONCLUSIONS Any drug resistance in previously treated TB cases among HIV-infected patients remains high. The risk of death is increasing in MDR-TB/HIV co-infected patients.
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Affiliation(s)
- Parvaneh Baghaei
- Clinical Tuberculosis and Epidemiology Research Center (CTERC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Tabarsi
- Clinical Tuberculosis and Epidemiology Research Center (CTERC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Afshin Moniri
- Clinical Tuberculosis and Epidemiology Research Center (CTERC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Marjani
- Clinical Tuberculosis and Epidemiology Research Center (CTERC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Parissa Farnia
- Mycobacteriology Research Center (MRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sayena Jabbehdari
- Students' Research Committee, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Velayati
- Clinical Tuberculosis and Epidemiology Research Center (CTERC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran; Mycobacteriology Research Center (MRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Saidi T, Salie F, Douglas TS. Towards understanding the drivers of policy change: a case study of infection control policies for multi-drug resistant tuberculosis in South Africa. Health Res Policy Syst 2017; 15:41. [PMID: 28558838 PMCID: PMC5450238 DOI: 10.1186/s12961-017-0203-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 05/08/2017] [Indexed: 11/10/2022] Open
Abstract
Background Explaining policy change is one of the central tasks of contemporary policy analysis. In this article, we examine the changes in infection control policies for multi-drug resistant tuberculosis (MDR-TB) in South Africa from the time the country made the transition to democracy in 1994, until 2015. We focus on MDR-TB infection control and refer to decentralised management as a form of infection control. Using Kingdon’s theoretical framework of policy streams, we explore the temporal ordering of policy framework changes. We also consider the role of research in motivating policy changes. Methods Policy documents addressing MDR-TB in South Africa over the period 1994 to 2014 were extracted. Literature on MDR-TB infection control in South Africa was extracted from PubMed using key search terms. The documents were analysed to identify the changes that occurred and the factors driving them. Results During the period under study, five different policy frameworks were implemented. The policies were meant to address the overwhelming challenge of MDR-TB in South Africa, contextualised by high prevalence of HIV infection, that threatened to undermine public health programmes and the success of antiretroviral therapy rollouts. Policy changes in MDR-TB infection control were supported by research evidence and driven by the high incidence and complexity of the disease, increasing levels of dissatisfaction among patients, challenges of physical, human and financial resources in public hospitals, and the ideologies of the political leadership. Activists and people living with HIV played an important role in highlighting the importance of MDR-TB as well as exerting pressure on policymakers, while the mass media drew public attention to infection control as both a cause of and a solution to MDR-TB. Conclusion The critical factors for policy change for infection control of MDR-TB in South Africa were rooted in the socioeconomic and political environment, were supported by extensive research, and can be framed using Kingdon’s policy streams approach as an interplay of the problem of the disease, political forces that prevailed and alternative proposals.
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Affiliation(s)
- Trust Saidi
- Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, P. Bag X3, Observatory, 7935, Cape Town, South Africa.
| | - Faatiema Salie
- Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, P. Bag X3, Observatory, 7935, Cape Town, South Africa
| | - Tania S Douglas
- Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, P. Bag X3, Observatory, 7935, Cape Town, South Africa
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Haberer JE, Sabin L, Amico KR, Orrell C, Galárraga O, Tsai AC, Vreeman RC, Wilson I, Sam‐Agudu NA, Blaschke TF, Vrijens B, Mellins CA, Remien RH, Weiser SD, Lowenthal E, Stirratt MJ, Sow PS, Thomas B, Ford N, Mills E, Lester R, Nachega JB, Bwana BM, Ssewamala F, Mbuagbaw L, Munderi P, Geng E, Bangsberg DR. Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations. J Int AIDS Soc 2017; 20:21371. [PMID: 28630651 PMCID: PMC5467606 DOI: 10.7448/ias.20.1.21371] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.
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Affiliation(s)
- Jessica E. Haberer
- Massachusetts General Hospital Global Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lora Sabin
- Department of Global Health, Center for Global Health and Department, Boston University School of Public Health, Boston, MA, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Nadia A. Sam‐Agudu
- Clinical Department, Institute of Human Virology Nigeria, Abuja, Nigeria
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terrence F. Blaschke
- Department of Medicine and Clinical Pharmacology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
- WestRock Healthcare, Sion, Switzerland
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Sheri D. Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth Lowenthal
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J. Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, MD, USA
| | - Papa Salif Sow
- Bill and Melinda Gates Foundation, Seattle, WA, USA
- Department of Infectious diseases, University of Dakar, Dakar, Sénégal
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Edward Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia
| | - Jean B. Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Bosco Mwebesa Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred Ssewamala
- Columbia University School of Social Work & School of International and Public Affairs, New York, NY, USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paula Munderi
- HIV Care Research Program, Medical Research Council, Uganda Virus Research Institute, Entebbe, Uganda
| | - Elvin Geng
- Division of HIV, Infectious Disease and Global Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA, USA
| | - David R. Bangsberg
- Oregon Health & Sciences University‐Portland State University School of Public Health, Portland, OR, USA
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Bastos ML, Lan Z, Menzies D. An updated systematic review and meta-analysis for treatment of multidrug-resistant tuberculosis. Eur Respir J 2017; 49:49/3/1600803. [PMID: 28331031 DOI: 10.1183/13993003.00803-2016] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 01/10/2017] [Indexed: 11/05/2022]
Abstract
This systematic review aimed to update the current evidence for multidrug-resistant tuberculosis (MDR-TB) treatment.We searched for studies that reported treatment information and clinical characteristics for at least 25 patients with microbiologically confirmed pulmonary MDR-TB and either end of treatment outcomes, 6-month culture conversion or severe adverse events (SAEs). We assessed the association of these outcomes with patients' characteristics or treatment parameters. We identified 74 studies, including 17 494 participants.The pooled treatment success was 26% in extensively drug-resistant TB (XDR-TB) patients and 60% in MDR-TB patients. Treatment parameters such as number or duration and individual drugs were not associated with improved 6-month sputum culture conversion or end of treatment outcomes. However, MDR-TB patients that received individualised regimens had higher success than patients who received standardised regimens (64% versus 52%; p<0.0.01). When reports from 20 cohorts were pooled, proportions of SAE ranged from 0.5% attributed to ethambutol to 12.2% attributed to para-aminosalicylic acid. The lack of significant associations of treatment outcomes with specific drugs or regimens may reflect the limitations of pooling the data rather than a true lack of differences in efficacy of regimens or individual drugs.This analysis highlights the need for stronger evidence for treatment of MDR-TB from better-designed and reported studies.
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Affiliation(s)
- Mayara Lisboa Bastos
- Internal Medicine Graduate Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Zhiyi Lan
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, QC, Canada
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Dheda K, Gumbo T, Maartens G, Dooley KE, McNerney R, Murray M, Furin J, Nardell EA, London L, Lessem E, Theron G, van Helden P, Niemann S, Merker M, Dowdy D, Van Rie A, Siu GKH, Pasipanodya JG, Rodrigues C, Clark TG, Sirgel FA, Esmail A, Lin HH, Atre SR, Schaaf HS, Chang KC, Lange C, Nahid P, Udwadia ZF, Horsburgh CR, Churchyard GJ, Menzies D, Hesseling AC, Nuermberger E, McIlleron H, Fennelly KP, Goemaere E, Jaramillo E, Low M, Jara CM, Padayatchi N, Warren RM. The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis. THE LANCET. RESPIRATORY MEDICINE 2017; 5:S2213-2600(17)30079-6. [PMID: 28344011 DOI: 10.1016/s2213-2600(17)30079-6] [Citation(s) in RCA: 376] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/24/2016] [Accepted: 12/08/2016] [Indexed: 12/25/2022]
Abstract
Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruth McNerney
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Megan Murray
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Edward A Nardell
- TH Chan School of Public Health, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Leslie London
- School of Public Health and Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Grant Theron
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Paul van Helden
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; German Centre for Infection Research (DZIF), Partner Site Borstel, Borstel, Schleswig-Holstein, Germany
| | - Matthias Merker
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Annelies Van Rie
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; International Health Unit, Epidemiology and Social Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Gilman K H Siu
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Camilla Rodrigues
- Department of Microbiology, P.D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | - Taane G Clark
- Faculty of Infectious and Tropical Diseases and Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Frik A Sirgel
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Sachin R Atre
- Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA; Medical College, Hospital and Research Centre, Pimpri, Pune, India
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong SAR, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, German Center for Infection Research, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden; Department of Medicine, University of Namibia School of Medicine, Windhoek, Namibia
| | - Payam Nahid
- Division of Pulmonary and Critical Care, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Zarir F Udwadia
- Pulmonary Department, Hinduja Hospital & Research Center, Mumbai, India
| | | | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Division of Intramural Research, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Eric Goemaere
- MSF South Africa, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Marcus Low
- Treatment Action Campaign, Johannesburg, South Africa
| | | | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Robin M Warren
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
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The experience of scaling up a decentralized, ambulatory model of care for management of multidrug-resistant tuberculosis in two regions of Ethiopia. J Clin Tuberc Other Mycobact Dis 2017; 7:28-33. [PMID: 31723698 PMCID: PMC6850264 DOI: 10.1016/j.jctube.2017.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/13/2017] [Accepted: 03/03/2017] [Indexed: 11/22/2022] Open
Abstract
Strong strategies, including proven service delivery models, are needed to address the growing global threat of multidrug-resistant tuberculosis (MDR-TB) in low- and middle-income settings. The objective of this study was to assess the feasibility and effectiveness of the nationally approved ambulatory service delivery model for MDR-TB treatment in two regions of Ethiopia. We used routinely reported data to describe the process and outcomes of implementing an ambulatory model for MDR-TB services in a resource-limited setting. We compared percentage improvements in the number of MDR-TB diagnostic and treatment facilities, number of MDR-TB sputum samples processed per year, and MDR-TB cases ever enrolled in care between baseline and 2015. We also calculated interim and final treatment outcomes for patients who had completed at least 12 and 24 months of follow-up, respectively. Between 2012 and 2015, the number of MDR-TB treatment-initiating centers increased from 1 to 23. The number of sputum samples tested for MDR-TB increased 20-fold, from 662 to 14,361 per year. The backlog of patients on waiting lists was cleared. The cumulative number of MDR-TB patients put on treatment increased from 56 to 790, and the treatment success rate was 75%. Rapid expansion of the ambulatory model of MDR-TB care was feasible and achieved a high treatment success rate in two regions of Ethiopia. More effort is needed to sustain the gains and further decentralize services to the community level.
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Alkabab Y, Keller S, Dodge D, Houpt E, Staley D, Heysell S. Early interventions for diabetes related tuberculosis associate with hastened sputum microbiological clearance in Virginia, USA. BMC Infect Dis 2017; 17:125. [PMID: 28166721 PMCID: PMC5294910 DOI: 10.1186/s12879-017-2226-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/27/2017] [Indexed: 11/29/2022] Open
Abstract
Background Diabetes complicates tuberculosis (TB) treatment including a prolonged time of sputum culture conversion to negative growth. Since 2013 in Virginia, interventions early in the treatment course have used therapeutic drug monitoring and dose correction for isoniazid and rifampin after 2 weeks of TB treatment in patients with diabetes along with nurse manager initiated diabetes education and linkage to care. Methods A retrospective cohort study of the state TB registry was performed for patients initiating drug-susceptible pulmonary TB treatment that were matched for age, gender, chest imaging and sputum smear status to compare time to sputum culture conversion and other clinical outcomes in the pre-and post-intervention groups. Results Three hundred sixty-three patients had documented time to sputum culture conversion in the pre-and post-intervention periods, including 56 (15%) with diabetes. Seventy-four (57%) of all patients with diabetes were ≥60 years of age at treatment initiation. Twenty-six patients with diabetes were matched in each group. Mean time to sputum culture conversion in the post-intervention group was 42 ± 22 days compared to the pre-intervention group of 62 ± 31 days (p = 0.01). In the post-intervention group 21 (80%) of patients with diabetes had culture conversion by 2 months compared to 13 (50%) in the pre-intervention group (p = 0.04). Conclusions Early interventions for diabetes related TB in the programmatic setting may hasten sputum culture conversion.
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Affiliation(s)
- Yosra Alkabab
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, P.O. Box 801340, Charlottesville, VA, 22908, USA.
| | - Suzanne Keller
- Division of Disease Prevention, TB Control, Virginia Department of Health, 109 Governor Street, Richmond, VA, 23219, USA
| | - Denise Dodge
- TB Control and Newcomer Health, Virginia Department of Health, PO Box 2448, 109 Governor Street, Room 326, Richmond, VA, 23218, USA
| | - Eric Houpt
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, P.O. Box 801340, Charlottesville, VA, 22908, USA
| | - Deborah Staley
- TB Control and Newcomer Health, Virginia Department of Health, PO Box 2448, 109 Governor Street, Room 326, Richmond, VA, 23218, USA
| | - Scott Heysell
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, P.O. Box 801340, Charlottesville, VA, 22908, USA
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Heysell SK, Ogarkov OB, Zhdanova S, Zorkaltseva E, Shugaeva S, Gratz J, Vitko S, Savilov ED, Koshcheyev ME, Houpt ER. Undertreated HIV and drug-resistant tuberculosis at a referral hospital in Irkutsk, Siberia. Int J Tuberc Lung Dis 2017; 20:187-92. [PMID: 26792470 DOI: 10.5588/ijtld.14.0961] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING A referral hospital for tuberculosis (TB) in Irkutsk, the Russian Federation. OBJECTIVE To describe disease characteristics, treatment and hospital outcomes of TB-HIV (human immunodeficiency virus). DESIGN Observational cohort of HIV-infected patients admitted for anti-tuberculosis treatment over 6 months. RESULTS A total of 98 patients were enrolled with a median CD4 count of 147 cells/mm(3) and viral load of 205 943 copies/ml. Among patients with drug susceptibility testing (DST) results, 29 (64%) were multidrug-resistant (MDR), including 12 without previous anti-tuberculosis treatment. Nineteen patients were on antiretroviral therapy (ART) at admission, and 10 (13% ART-naïve) were started during hospitalization. Barriers to timely ART initiation included death, in-patient treatment interruption, and patient refusal. Of 96 evaluable patients, 21 (22%) died, 14 (15%) interrupted treatment, and 10 (10%) showed no microbiological or radiographic improvement. Patients with a cavitary chest X-ray (aOR 7.4, 95%CI 2.3-23.7, P = 0.001) or central nervous system disease (aOR 6.5, 95%CI 1.2-36.1, P = 0.03) were more likely to have one of these poor outcomes. CONCLUSION High rates of MDR-TB, treatment interruption and death were found in an HIV-infected population hospitalized in Irkutsk. There are opportunities for integration of HIV and TB services to overcome barriers to timely ART initiation, increase the use of anti-tuberculosis regimens informed by second-line DST, and strengthen out-patient diagnosis and treatment networks.
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Affiliation(s)
- S K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - O B Ogarkov
- Scientific Centre for Family Health and Human Reproduction Problems, Irkutsk, Russian Federation; Regional TB Prevention Dispensary, Irkutsk, Russian Federation
| | - S Zhdanova
- Scientific Centre for Family Health and Human Reproduction Problems, Irkutsk, Russian Federation
| | - E Zorkaltseva
- Regional TB Prevention Dispensary, Irkutsk, Russian Federation; State Medical Continuing Education Academy, Irkutsk, Russian Federation
| | - S Shugaeva
- Regional TB Prevention Dispensary, Irkutsk, Russian Federation
| | - J Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - S Vitko
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - E D Savilov
- Scientific Centre for Family Health and Human Reproduction Problems, Irkutsk, Russian Federation; State Medical Continuing Education Academy, Irkutsk, Russian Federation
| | - M E Koshcheyev
- Regional TB Prevention Dispensary, Irkutsk, Russian Federation
| | - E R Houpt
- *Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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Bieh KL, Weigel R, Smith H. Hospitalized care for MDR-TB in Port Harcourt, Nigeria: a qualitative study. BMC Infect Dis 2017; 17:50. [PMID: 28068907 PMCID: PMC5223486 DOI: 10.1186/s12879-016-2114-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 12/14/2016] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND In Nigeria multidrug-resistant tuberculosis (MDR-TB) is prevalent in 2.9% of new TB cases and 14% of retreatment cases, and the country is one of 27 with high disease burden globally. Patients are admitted and confined to one of ten MDR-TB treatment facilities throughout the initial 8 months of treatment. The perspectives of MDR-TB patients shared on social media and in academic research and those of providers are limited to experiences of home-based care. In this study we explored the views of hospitalised MDR-TB patients and providers in one treatment facility in Nigeria, and describe how their experiences are linked to accessibility of care and support services, in line with international goals. We aimed to explore the physical, social and psychological needs of hospitalized MDR TB patients, examine providers' perceptions about the hospital based model and discuss the model's advantages and disadvantages from the patient and the provider perspective. METHODS We conducted two gender distinct focus group discussions and 11 in-depth interviews with recently discharged MDR-TB patients from one MDR-TB treatment facility in Nigeria. We triangulated this with the views of four providers who played key roles in the management of MDR-TB patients via key informant interviews. Transcribed data was thematically analysed, using an iterative process to constantly compare and contrast emerging themes across the data set for deeper understanding of the full range of participants' views. RESULTS The study findings demonstrate the psycho-social impacts of prolonged isolation and the coping mechanisms of patients in the facility. The dislocation of patients from their normal social networks and the detachment between providers and patients created the need for interdependence of patients for emotional and physical support. Providers' fears of infection contributed to stigma and hindered accessibility of care and support services. CONCLUSION The current trend towards discharging patients after culture conversion would reduce the psycho-social impacts of prolonged isolation and potentially reduce the risk of occupational TB from prolonged contact with MDR-TB patients. Building on shared experiences and interdependence of MDR-TB patients in our study, innovative patient-centred support systems would likely help to reduce stigma, promote access to care and support services, and potentially impact on the outcome of treatment.
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Affiliation(s)
- Kingsley Lezor Bieh
- State TB and Leprosy Control Programme, Rivers State Ministry of Health, Port Harcourt, Nigeria
| | - Ralf Weigel
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Smith
- Liverpool School of Tropical Medicine, Liverpool, UK
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O'Donnell MR, Daftary A, Frick M, Hirsch-Moverman Y, Amico KR, Senthilingam M, Wolf A, Metcalfe JZ, Isaakidis P, Davis JL, Zelnick JR, Brust JCM, Naidu N, Garretson M, Bangsberg DR, Padayatchi N, Friedland G. Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIV. Int J Tuberc Lung Dis 2017; 20:430-4. [PMID: 26970149 DOI: 10.5588/ijtld.15.0360] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite renewed focus on molecular tuberculosis (TB) diagnostics and new antimycobacterial agents, treatment outcomes for patients co-infected with drug-resistant TB and human immunodeficiency virus (HIV) remain dismal, in part due to lack of focus on medication adherence as part of a patient-centered continuum of care. OBJECTIVE To review current barriers to drug-resistant TB-HIV treatment and propose an alternative model to conventional approaches to treatment support. DISCUSSION Current national TB control programs rely heavily on directly observed therapy (DOT) as the centerpiece of treatment delivery and adherence support. Medication adherence and care for drug-resistant TB-HIV could be improved by fully implementing team-based patient-centered care, empowering patients through counseling and support, maintaining a rights-based approach while acknowledging the responsibility of health care systems in providing comprehensive care, and prioritizing critical research gaps. CONCLUSION It is time to re-invent our understanding of adherence in drug-resistant TB and HIV by focusing attention on the complex clinical, behavioral, social, and structural needs of affected patients and communities.
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Affiliation(s)
- M R O'Donnell
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA; Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - A Daftary
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - M Frick
- Treatment Action Group, New York, USA
| | - Y Hirsch-Moverman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA; International Center for AIDS Care and Treatment Programs, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - K R Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | | | - A Wolf
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - J Z Metcalfe
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
| | | | - J L Davis
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - J R Zelnick
- Touro College Graduate School of Social Work, New York, New York, USA
| | - J C M Brust
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York, USA
| | - N Naidu
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - M Garretson
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | | | - N Padayatchi
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - G Friedland
- Yale University School of Public Health, New Haven, Connecticut, USA; Yale University School of Medicine, New Haven, Connecticut, USA
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Ogarkov OB, Ebers A, Zhdanova S, Moiseeva E, Koshcheyev ME, Zorkaltseva E, Shugaeva S, Vitko S, Lyles G, Houpt ER, Heysell SK. Administrative interventions associated with increased initiation on antiretroviral therapy in Irkutsk, Siberia. Public Health Action 2016; 6:252-254. [PMID: 28123963 DOI: 10.5588/pha.16.0050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/11/2016] [Indexed: 11/10/2022] Open
Abstract
A bundle of initiatives to integrate human immunodeficiency virus (HIV) and tuberculosis (TB) services was assessed for the impact on antiretroviral therapy (ART) initiation at a TB referral hospital in Irkutsk, Russian Federation, from February 2014 to December 2015. The ART initiation rates in 166 ART-naïve patients undergoing anti-tuberculosis treatment (34.1% with multidrug or extensively drug-resistant TB) increased significantly from 14 (17%) pre-intervention to 44 (54%) post-intervention (P < 0.001). A survey of TB hospital staff identified administrative prioritisation as the most important initiative for increasing ART initiation.
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Affiliation(s)
- O B Ogarkov
- Scientific Centre for Family Health and Human Reproduction Problems, Irkutsk, Russian Federation ; Regional Tuberculosis Prevention Dispensary, Irkutsk, Russian Federation
| | - A Ebers
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - S Zhdanova
- Scientific Centre for Family Health and Human Reproduction Problems, Irkutsk, Russian Federation
| | - E Moiseeva
- Regional Tuberculosis Prevention Dispensary, Irkutsk, Russian Federation
| | - M E Koshcheyev
- Regional Tuberculosis Prevention Dispensary, Irkutsk, Russian Federation
| | - E Zorkaltseva
- Regional Tuberculosis Prevention Dispensary, Irkutsk, Russian Federation ; State Medical Continuing Education Academy, Irkutsk, Russian Federation
| | - S Shugaeva
- Regional Tuberculosis Prevention Dispensary, Irkutsk, Russian Federation
| | - S Vitko
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - G Lyles
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - E R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - S K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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Alffenaar JWC, Akkerman OW, Anthony RM, Tiberi S, Heysell S, Grobusch MP, Cobelens FG, Van Soolingen D. Individualizing management of extensively drug-resistant tuberculosis: diagnostics, treatment, and biomarkers. Expert Rev Anti Infect Ther 2016; 15:11-21. [PMID: 27762157 DOI: 10.1080/14787210.2017.1247692] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Success rates for treatment of extensively drug resistant tuberculosis (XDR-TB) are low due to limited treatment options, delayed diagnosis and inadequate health care infrastructure. Areas covered: This review analyses existing programmes of prevention, diagnosis and treatment of XDR-TB. Improved diagnostic procedures and rapid molecular tests help to select appropriate drugs and dosages. Drugs dosages can be further tailored to the specific conditions of the patient based on quantitative susceptibility testing of the M. tuberculosis isolate and use of therapeutic drug monitoring. Pharmacovigilance is important for preserving activity of the novel drugs bedaquiline and delamanid. Furthermore, biomarkers of treatment response must be developed and validated to guide therapeutic decisions. Expert commentary: Given the currently poor treatment outcomes and the association of XDR-TB with HIV in endemic regions, a more patient oriented approach regarding diagnostics, drug selection and tailoring and treatment evaluation will improve treatment outcome. The different areas of expertise should be covered by a multidisciplinary team and may involve the transition of patients from hospitalized to home or community-based treatment.
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Affiliation(s)
- Jan-Willem C Alffenaar
- a Dept of Clinical Pharmacy and Pharmacology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Onno W Akkerman
- b University of Groningen, University Medical Center Groningen, Tuberculosis Center Beatrixoord , Haren , The Netherlands.,c Department of Pulmonary Diseases and Tuberculosis , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Richard M Anthony
- d Royal Tropical Institute (KIT), KIT Biomedical Research , Amsterdam , The Netherlands
| | - Simon Tiberi
- e Division of Infection , Barts Healthcare NHS Trust , London , United Kingdom
| | - Scott Heysell
- f Division of Infectious Diseases and International Health , University of Virginia , Charlottesville , VA , USA
| | - Martin P Grobusch
- g Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center , University of Amsterdam , Amsterdam , The Netherlands
| | - Frank G Cobelens
- h Department of Global Health, Academic Medical Centre , University of Amsterdam , Amsterdam , The Netherlands.,i Amsterdam Institute for Global Health and Development , Amsterdam , The Netherlands.,j KNCV Tuberculosis Foundation , The Hague , The Netherlands
| | - Dick Van Soolingen
- k National Tuberclosis Reference Laboratory , National Institute for Public Health and the Environment (RIVM) , Bilthoven , The Netherlands.,l Radboud University Nijmegen Medical Center , Departments of Pulmonary Diseases and Medical Microbiology , Nijmegen , The Netherlands
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Williams AO, Makinde OA, Ojo M. Community-based management versus traditional hospitalization in treatment of drug-resistant tuberculosis: a systematic review and meta-analysis. Glob Health Res Policy 2016; 1:10. [PMID: 29202059 PMCID: PMC5693550 DOI: 10.1186/s41256-016-0010-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/25/2016] [Indexed: 11/10/2022] Open
Abstract
Background Multidrug drug resistant Tuberculosis (MDR-TB) and extensively drug resistant Tuberculosis (XDR-TB) have emerged as significant public health threats worldwide. This systematic review and meta-analysis aimed to investigate the effects of community-based treatment to traditional hospitalization in improving treatment success rates among MDR-TB and XDR-TB patients in the 27 MDR-TB High burden countries (HBC). Methods We searched PubMed, Cochrane, Lancet, Web of Science, International Journal of Tuberculosis and Lung Disease, and Centre for Reviews and Dissemination (CRD) for studies on community-based treatment and traditional hospitalization and MDR-TB and XDR-TB from the 27 MDR-TB HBC. Data on treatment success and failure rates were extracted from retrospective and prospective cohort studies, and a case control study. Sensitivity analysis, subgroup analyses, and meta-regression analysis were used to explore bias and potential sources of heterogeneity. Results The final sample included 16 studies involving 3344 patients from nine countries; Bangladesh, China, Ethiopia, Kenya, India, South Africa, Philippines, Russia, and Uzbekistan. Based on a random-effects model, we observed a higher treatment success rate in community-based treatment (Point estimate = 0.68, 95 % CI: 0.59 to 0.76, p < 0.01) compared to traditional hospitalization (Point estimate = 0.57, 95 % CI: 0.44 to 0.69, p < 0.01). A lower treatment failure rate was observed in community-based treatment 7 % (Point estimate = 0.07, 95 % CI: 0.03 to 0.10; p < 0.01) compared to traditional hospitalization (Point estimate = 0.188, 95 % CI: 0.10 to 0.28; p < 0.01). In the subgroup analysis, studies without HIV co-infected patients, directly observed therapy short course-plus (DOTS-Plus) implemented throughout therapy, treatment duration > 18 months, and regimen with drugs >5 reported higher treatment success rate. In the meta-regression model, age of patients, adverse events, treatment duration, and lost to follow up explains some of the heterogeneity of treatment effects between studies. Conclusion Community-based management improved treatment outcomes. A mix of interventions with DOTS-Plus throughout therapy and treatment duration > 18 months as well as strategies in place for lost to follow up and adverse events should be considered in MDR-TB and XDR-TB interventions, as they influenced positively, treatment success.
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Affiliation(s)
- Abimbola Onigbanjo Williams
- School of Public Health, Rutgers, The State University of New Jersey, 683 Hoes Lane, Piscataway, New Brunswick, 08854 NJ USA.,Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Brunswick, NJ USA
| | - Olusesan Ayodeji Makinde
- Viable Knowledge Masters, 22 Olusegun Obasanjo Street, Peace Court Estate, Lokogoma, Abuja Nigeria.,Demography and Population Studies Program, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mojisola Ojo
- School of Public Health, Rutgers, The State University of New Jersey, 683 Hoes Lane, Piscataway, New Brunswick, 08854 NJ USA
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Maharaj J, Ross A, Maharaj NR, Campbell L. Multidrug-resistant tuberculosis in KwaZulu-Natal, South Africa: An overview of patients' reported knowledge and attitudes. Afr J Prim Health Care Fam Med 2016; 8:e1-6. [PMID: 27380789 PMCID: PMC4926722 DOI: 10.4102/phcfm.v8i1.1089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 02/12/2016] [Accepted: 01/29/2016] [Indexed: 11/12/2022] Open
Abstract
Background The incidence and prevalence of multidrug–resistant tuberculosis (MDR TB) in the province of KwaZulu-Natal, South Africa, are amongst the highest in the world. Previously, interventions have been largely biomedical based; however, there is growing opinion that interventions must include social aspects such as patient education and attitudes. Methods This observational study assessed the knowledge and attitudes of 380 patients diagnosed with MDR TB at a centralised MDR TB unit in Durban. Data were collected using a questionnaire that was distributed to every third patient attending the outpatient MDR TB clinic. Data were collected over an 8-week period and analysed descriptively. Results Just under half of the respondents had primary MDR TB. Most respondents were young, female unemployed and did not receive a social grant. Knowledge around diagnosis of MDR TB was generally adequate. There were important misconceptions about spread of the disease and duration of treatment. Most respondents received knowledge of MDR TB from healthcare workers. Some respondents received knowledge from friends, family and Sangomas and believed that the disease was caused by bewitchment or as a form of punishment. Discussion The need for strengthening the role of primary care physicians in promoting education and providing support is highlighted. Further study is needed to investigate the high rate of primary MDR TB and to identify the unique challenges faced by women who have MDR TB. Future research could include the possibility of involving traditional healers in a contextually sensitive MDR TB education, training and support programme.
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Banerjee R, Starke JR. What tuberculosis can teach us about combating multidrug-resistant Gram negative bacilli. J Clin Tuberc Other Mycobact Dis 2016; 3:28-34. [PMID: 31723682 PMCID: PMC6850263 DOI: 10.1016/j.jctube.2016.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 03/15/2016] [Accepted: 03/18/2016] [Indexed: 12/03/2022] Open
Abstract
There are striking similarities between the dual pandemics of multidrug-resistant tuberculosis (MDR TB) and multidrug-resistant Gram negative bacilli (MDR GNB) despite fundamental differences in the pathogenesis and epidemiology of these pathogens. In this perspective, we highlight several strategies that have been used by the global TB community to address the MDR TB problem, including approaches to: encourage appropriate use of anti-TB medications, enhance appropriate utilization of molecular diagnostic testing, facilitate development of new antimicrobial agents, and strengthen surveillance systems and infection control practices. Understanding the successes and challenges of these strategies for MDR TB control will be instructive for efforts to curb emergence and spread of MDR GNB.
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Thomas BE, Shanmugam P, Malaisamy M, Ovung S, Suresh C, Subbaraman R, Adinarayanan S, Nagarajan K. Psycho-Socio-Economic Issues Challenging Multidrug Resistant Tuberculosis Patients: A Systematic Review. PLoS One 2016; 11:e0147397. [PMID: 26807933 PMCID: PMC4726571 DOI: 10.1371/journal.pone.0147397] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 01/04/2016] [Indexed: 11/18/2022] Open
Abstract
Background Limited treatment options, long duration of treatment and associated toxicity adversely impact the physical and mental well-being of multidrug-resistant tuberculosis (MDR-TB) patients. Despite research advances in the microbiological and clinical aspects of MDR-TB, research on the psychosocial context of MDR-TB is limited and less understood. Methodology We searched the databases of PubMed, MEDLINE, Embase and Google Scholar to retrieve all published articles. The final manuscripts included in the review were those with a primary focus on psychosocial issues of MDR-TB patients. These were assessed and the information was thematically extracted on the study objective, methodology used, key findings, and their implications. Intervention studies were evaluated using components of the methodological and quality rating scale. Due to the limited number of studies and the multiple methodologies employed in the observational studies, we summarized these studies using a narrative approach, rather than conducting a formal meta-analysis. We used ‘thematic synthesis’ method for extracting qualitative evidences and systematically organised to broader descriptive themes. Results A total of 282 published articles were retrieved, of which 15 articles were chosen for full text review based on the inclusion criteria. Six were qualitative studies; one was a mixed methods study; and eight were quantitative studies. The included studies were divided into the following issues affecting MDR-TB patients: a) psychological issues b) social issues and economic issues c) psychosocial interventions. It was found that all studies have documented range of psychosocial and economic challenges experienced by MDR-TB patients. Depression, stigma, discrimination, side effects of the drugs causing psychological distress, and the financial constraints due to MDR-TB were some of the common issues reported in the studies. There were few intervention studies which addressed these psychosocial issues most of which were small pilot studies. There is dearth of large scale randomized psychosocial intervention studies that can be scaled up to strengthen management of MDR-TB patients which is crucial for the TB control programme. Conclusion This review has captured the psychosocial and economic issues challenging MDR patients. However there is urgent need for feasible, innovative psychosocial and economic intervention studies that help to equip MDR-TB patients cope with their illness, improve treatment adherence, treatment outcomes and the overall quality of life of MDR-TB patients.
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Affiliation(s)
- Beena Elizabeth Thomas
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), ICMR, Chennai, India
- * E-mail:
| | - Poonguzhali Shanmugam
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), ICMR, Chennai, India
| | - Muniyandi Malaisamy
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), ICMR, Chennai, India
| | - Senthanro Ovung
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), ICMR, Chennai, India
| | - Chandra Suresh
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), ICMR, Chennai, India
| | - Ramnath Subbaraman
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | | | - Karikalan Nagarajan
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), ICMR, Chennai, India
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Primary Capreomycin Resistance Is Common and Associated With Early Mortality in Patients With Extensively Drug-Resistant Tuberculosis in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr 2015; 69:536-43. [PMID: 25886924 DOI: 10.1097/qai.0000000000000650] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Capreomycin is a key antimycobacterial drug in treatment of extensively drug-resistant tuberculosis (XDR-TB). Drug-susceptibility testing (DST) for capreomycin is not routinely performed in newly diagnosed XDR-TB in South Africa. We performed this study to assess the prevalence, clinical significance, and molecular epidemiology of capreomycin resistance in newly diagnosed patients with XDR-TB in KwaZulu-Natal, South Africa. METHODS Retrospective cohort study of consecutive patients with XDR-TB admitted to a TB referral hospital without previous XDR-TB treatment. A subset of isolates had extended DST (including capreomycin), mutational analysis, and IS6110 restriction fragment length polymorphism assays. RESULTS A total of 216 eligible patients with XDR-TB were identified. The majority were treated with capreomycin (72%), were young (median age: 35.5 years), and were female (56%). One hundred five (76%) were HIV+, and 109 (66%) were on antiretroviral therapy. A subset of 52 patients had full DST. A total of 47/52 (90.4%) patients with XDR-TB were capreomycin resistant. Capreomycin-resistant patients experienced worse mortality and culture conversion than capreomycin susceptible, although this difference was not statistically significant. The A1401G mutation in the rrs gene was associated with capreomycin resistance. The majority of capreomycin-resistant strains were F15/LAM4/KZN lineage (80%), and clustering was common in these isolates (92.5%). CONCLUSIONS Capreomycin resistance is common in patients with XDR-TB in KwaZulu-Natal, is predominantly because of ongoing province-wide transmission of a highly resistant strain, and is associated with high mortality. Capreomycin should be included in routine DST in all patients with XDR-TB. New drug regimens that do not include injectable agents should be operationally tested as empiric treatment in XDR-TB.
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Jong E, Sanne IM, van Rie A, Menezes CN. A hospital-based tuberculosis focal point to improve tuberculosis care provision in a very high burden setting. Public Health Action 2015; 3:51-5. [PMID: 26392996 DOI: 10.5588/pha.12.0073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 01/22/2013] [Indexed: 11/10/2022] Open
Abstract
SETTING A hospital-based tuberculosis focal point (TBFP) at a tertiary hospital in Johannesburg, South Africa. OBJECTIVE To describe the possible tasks and impact of a hospital-based TBFP as well as staffing and infrastructure requirements for setting up a hospital-based TBFP. ACTIVITIES A TBFP can centralize the notification and referral of new TB cases, perform human immunodeficiency virus counseling and testing, assessment of difficult to diagnose TB suspects and management of complicated TB cases, and it can provide an ideal setting for research and health care worker training. RESULTS The number of TB suspects assessed by sputum initially increased, followed by a decrease starting in 2010, which correlates with the globally decreasing TB incidence. The proportion of TB cases who failed to link to TB care decreased from 23% to 14% between 2009 and 2012. Almost 40% of cases with hepatotoxicity required an adjusted treatment regimen. Roll-out of Xpert(®) MTB/RIF testing and decentralized drug-resistant TB treatment increased the number of rifampicin monoresistant and sputum smear-negative multidrug-resistant TB cases treated on an out-patient basis. CONCLUSION A hospital-based TBFP complements care at primary care level by coordinating TB care for a vulnerable population of patients diagnosed in a hospital setting, and by coordinating the diagnosis and treatment of complex TB cases.
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Affiliation(s)
- E Jong
- Clinical HIV Research Unit, Department of Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - I M Sanne
- Clinical HIV Research Unit, Department of Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - A van Rie
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - C N Menezes
- Helen Joseph Hospital, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Loveday M, Wallengren K, Brust J, Roberts J, Voce A, Margot B, Ngozo J, Master I, Cassell G, Padayatchi N. Community-based care vs. centralised hospitalisation for MDR-TB patients, KwaZulu-Natal, South Africa. Int J Tuberc Lung Dis 2015; 19:163-71. [PMID: 25574914 DOI: 10.5588/ijtld.14.0369] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING KwaZulu-Natal, South Africa, a predominantly rural province with a high burden of tuberculosis (TB), multidrug-resistant TB (MDR-TB) and human immunodeficiency virus (HIV) infection. OBJECTIVE To determine the most effective care model by comparing MDR-TB treatment outcomes at community-based sites with traditional care at a central, specialised hospital. DESIGN A non-randomised observational prospective cohort study comparing community-based and centralised care. Patients at community-based sites were closer to home and had easier access to care, and home-based care was available from treatment initiation. RESULTS Four community-based sites treated 736 patients, while 813 were treated at the centralised hospital (total = 1549 patients). Overall, 75% were HIV co-infected (community: 76% vs. hospitalised: 73%, P = 0.45) and 86% received antiretroviral therapy (community: 91% vs. hospitalised: 82%, P = 0.22). On multivariate analysis, MDR-TB patients were more likely to have a successful treatment outcome if they were treated at a community-based site (adjusted OR 1.43, P = 0.01). However, outcomes at the four community-based sites were heterogeneous, with Site 1 demonstrating that home-based care was associated with an increased treatment success of 72% compared with success rates of 52-60% at the other three sites. CONCLUSION Community-based care for MDR-TB patients was more effective than care in a central, specialised hospital. Home-based care further increased treatment success.
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Affiliation(s)
- M Loveday
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - K Wallengren
- TB and HIV Investigative Network (Think), Durban, South Africa
| | - J Brust
- Department of Medicine, Montefiore Medical Center & Albert Einstein College of Medicine, New York, New York, USA
| | - J Roberts
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - A Voce
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - B Margot
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | - J Ngozo
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | - I Master
- King Dinuzulu Hospital, Durban, South Africa
| | - G Cassell
- Harvard University School of Medicine, Boston, Massachusetts, USA
| | - N Padayatchi
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
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Gilbert JA, Long EF, Brooks RP, Friedland GH, Moll AP, Townsend JP, Galvani AP, Shenoi SV. Integrating Community-Based Interventions to Reverse the Convergent TB/HIV Epidemics in Rural South Africa. PLoS One 2015; 10:e0126267. [PMID: 25938501 PMCID: PMC4418809 DOI: 10.1371/journal.pone.0126267] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 03/31/2015] [Indexed: 12/22/2022] Open
Abstract
The WHO recommends integrating interventions to address the devastating TB/HIV co-epidemics in South Africa, yet integration has been poorly implemented and TB/HIV control efforts need strengthening. Identifying infected individuals is particularly difficult in rural settings. We used mathematical modeling to predict the impact of community-based, integrated TB/HIV case finding and additional control strategies on South Africa’s TB/HIV epidemics. We developed a model incorporating TB and HIV transmission to evaluate the effectiveness of integrating TB and HIV interventions in rural South Africa over 10 years. We modeled the impact of a novel screening program that integrates case finding for TB and HIV in the community, comparing it to status quo and recommended TB/HIV control strategies, including GeneXpert, MDR-TB treatment decentralization, improved first-line TB treatment cure rate, isoniazid preventive therapy, and expanded ART. Combining recommended interventions averted 27% of expected TB cases (95% CI 18–40%) 18% HIV (95% CI 13–24%), 60% MDR-TB (95% CI 34–83%), 69% XDR-TB (95% CI 34–90%), and 16% TB/HIV deaths (95% CI 12–29). Supplementing these interventions with annual community-based TB/HIV case finding averted a further 17% of TB cases (44% total; 95% CI 31–56%), 5% HIV (23% total; 95% CI 17–29%), 8% MDR-TB (68% total; 95% CI 40–88%), 4% XDR-TB (73% total; 95% CI 38–91%), and 8% TB/HIV deaths (24% total; 95% CI 16–39%). In addition to increasing screening frequency, we found that improving TB symptom questionnaire sensitivity, second-line TB treatment delays, default before initiating TB treatment or ART, and second-line TB drug efficacy were significantly associated with even greater reductions in TB and HIV cases. TB/HIV epidemics in South Africa were most effectively curtailed by simultaneously implementing interventions that integrated community-based TB/HIV control strategies and targeted drug-resistant TB. Strengthening existing TB and HIV treatment programs is needed to further reduce disease incidence.
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Affiliation(s)
- Jennifer A Gilbert
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States of America; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, United States of America
| | - Elisa F Long
- Anderson School of Management, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Ralph P Brooks
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, CT, United States of America
| | - Gerald H Friedland
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States of America; Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, CT, United States of America
| | - Anthony P Moll
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, CT, United States of America; Church of Scotland Hospital, Tugela Ferry, KwaZulu-Natal, South Africa
| | - Jeffrey P Townsend
- Department of Biostatistics, Yale University, New Haven, CT, United States of America; Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, United States of America; Program in Computational Biology and Informatics, Yale University, New Haven, CT, United States of America
| | - Alison P Galvani
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States of America; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, United States of America; Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, United States of America; Program in Computational Biology and Informatics, Yale University, New Haven, CT, United States of America
| | - Sheela V Shenoi
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, CT, United States of America
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