Effect of 6-month vs. 8-month regimen on retreatment success for pulmonary TB

Negative effects of undernutrition on sputum smear conversion and treatment success among retreatment cases in Uganda: A quasi-experimental study

Rationale

The causal relationship between undernutrition and response to anti-tuberculosis (TB) treatment and TB treatment outcomes among people with retreatment TB is understudied.

Objective

To evaluate the effect of undernutrition on treatment success and sputum smear conversion among people with retreatment drug-susceptible TB in Kampala, Uganda.

Methods

We conducted a quasi-experimental study utilizing propensity score weighting among people with retreatment drug-susceptible TB aged ≥ 15 years treated between 2012 and 2022 in Kampala. The primary exposure was undernutrition assessed using the mid-upper arm circumference at the time of TB diagnosis. The primary outcome was treatment success defined as cure or treatment completion at month 6. Sputum smear conversion was the secondary outcome and was measured as a change in sputum smear status from positive to negative at months 2, 5, and 6. We estimated the causal effect of undernutrition on the outcomes using a propensity-score weighted modified Poisson regression model with robust error variance.

Measurements and main results

Of the 605 participants, 432 (71.4 %) were male, 215 (35.5 %) were aged 25-34 years, 427 (70.6 %) had bacteriologically confirmed pulmonary TB, 133 (22.0 %) were undernourished and 398 (65.8 %) achieved treatment success. Of participants with bacteriologically confirmed pulmonary TB, 232 (59.0 %), 327 (59.3 %), and 360 (97.6 %) achieved sputum smear conversion at months 2, 5, and 6, respectively. Undernutrition reduced treatment success (RR 0.42, 95 % CI 0.32-0.55) as well as sputum smear conversion at months 2 (RR 0.45, 95 % CI 0.42-0.49) and 5 (RR 0.46, 95 % CI 0.43-0.51) but not month 6 (RR 0.99, 95 % CI 0.97-1.02).

Conclusion

Undernutrition negatively impacts treatment outcomes. Therefore, nutritional assessment should be an integral component of TB care, with nutritional counseling and support offered to those undernourished to optimize their TB treatment response and outcomes.

Barriers and facilitators to viral load suppression among people living with HIV following intensive adherence counseling in Kampala, Uganda: A qualitative study

We explored the barriers and facilitators to viral load (VL) suppression after three or more intensive adherence counseling (IAC) sessions among adolescents and adults living with human immunodeficiency virus (HIV) on a first-line anti-retroviral therapy (ART) with initially unsuppressed VL in Kampala, Uganda. Using a qualitative study, data were collected through in-depth interviews with people living with HIV (PLHIV) with unsuppressed and suppressed VL and caregivers of younger adolescents living with HIV after three or more IAC sessions. We held key informant interviews with health workers involved in IAC implementation, namely ART/HIV focal persons, IAC Team Leaders, and linkage facilitators. Guided by the socioecological model, we performed content analysis and reported the findings using themes along with the participants' quotes. We studied 24 participants and found the individual-level barriers as forgetting to take HIV medications, high pill burden, medication side effects, a lack of food, and HIV-related psychological distress. Undisclosed HIV status and broken families were the barriers at the interpersonal level. Institutional-level barriers included insufficient HIV and ART counseling. Stigma was considered a community-level barrier while nonadherence to HIV treatment guidelines was a policy-level barrier. Facilitators included personal reminders, knowing the importance of taking treatment, and the ability to deal with side effects of HIV medications at the personal level; treatment support, peer support clubs, and incentivized treatment at the interpersonal level; and mental health support club and explaining during counseling that HIV is a chronic disease at the institutional level. We found an unsuppressed VL after completing IAC was due to several barriers at the personal, interpersonal, health systems, community, and policy levels. Achieving ≥95% VL suppression necessitates tackling the barriers to VL suppression and scaling up the facilitators by HIV control programs.

Risk factors for unsuppressed viral load after intensive adherence counseling among HIV infected persons in Kampala, Uganda: a nested case-control study

BACKGROUND

Intensive adherence counseling (IAC) is the global standard of care for people living with human immunodeficiency virus (PLHIV) who have unsuppressed VL after ≥ 6 months of first-line anti-retroviral therapy (ART). We investigated whether the number of IAC sessions is associated with suppressed VL among PLHIV in Kampala, Uganda.

METHODS

We conducted a nested case-control study among PLHIV with unsuppressed VL after ≥ 3 IAC sessions (cases) and a 2:1 random sample of PLHIV with suppressed VL after ≥ 3 IAC sessions (controls). Unsuppressed VL was defined as VL ≥ 1000 copies/ml. We performed multivariable logistic regression to identify factors that differed significantly between cases and controls.

RESULTS

Demographic and clinical characteristics were similar among the 16 cases and 32 controls including mean age, sex, baseline CD4 count, VL before IAC, and WHO clinical stage. Only the number of IAC sessions differed significantly between cases and controls in unadjusted (p = 0.012) and adjusted (p = 0.016) analyses. Each unit increase in IAC session was associated with unsuppressed VL (Adjusted odds ratio 5.09; 95% CI 1.35-19.10).

CONCLUSIONS

VL remained unsuppressed despite increasing IAC frequency. The fidelity to standardized IAC protocol besides drug resistance testing among PLHIV with unsuppressed VL before IAC commencement should be examined.

Impact of intensive adherence counseling on viral load suppression and mortality among people living with HIV in Kampala, Uganda: A regression discontinuity design

Intensive adherence counseling (IAC) is recommended for people living with HIV (PLHIV) with viral load (VL) ≥1,000 copies/ml after ≥6 months of anti-retroviral therapy (ART). We evaluated the effect of IAC on VL suppression and all-cause mortality among PLHIV on first-line ART with VL ≥1,000 copies/ml after ≥6 months of ART in Kampala, Uganda using regression discontinuity design, a quasi-experimental method for effect estimation when interventions depend on a cut-off. PLHIV just above VL ≥1,000 copies/ml cut-off who received ≥3 IAC sessions formed the intervention group while those just below the cut-off who received routine psychosocial support constituted the control group. Primary outcome was repeat VL suppression defined as VL <1,000 copies/ml approximately 9-12 months following initial VL assessment. Secondary outcome was all-cause mortality. We used logistic regression for causal-effect analysis, reported as odds ratio (OR) with a 95% confidence interval (CI). We performed sensitivity analyses to assess the robustness of findings to varying bandwidths at the cut-off. We found 3,735 PLHIV were started on ART between Nov 2020 and Nov 2021 of whom 3,199 were included in the analysis (3,085 control, 114 intervention). Within an optimal bandwidth, there were 236 participants (222 control, 14 intervention) with similar demographic and clinical characteristics. Repeat VL suppression was lower in the intervention than in the control group (85.7% versus 98.6%, p = 0.021) while all-cause mortality was similar (0% versus 0.5%, p = 1.000). In multivariable analysis, the odds of repeat VL suppression were 91% lower in the intervention than control group (OR = 0.09; 95% CI, 0.01-0.66). Findings are robust to varying bandwidths around the cut-off. We concluded IAC is ineffective in suppressing VL among PLHIV on first-line ART in Kampala, Uganda. Findings suggest a need to investigate the IAC implementation fidelity for successful translation in practice and the reasons for VL persistence beyond the suppression threshold.

Low treatment success rate among previously treated persons with drug-susceptible pulmonary tuberculosis in Kampala, Uganda

Rationale

In 2017, the treatment regimen for previously treated persons with tuberculosis (TB) changed to a shorter regimen that lasts six months and consists of Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol. Few studies have examined treatment success rate (TSR) among previously treated persons with TB including the associated factors.

Objective

To determine TSR and the associated factors among previously treated persons with bacteriologically confirmed pulmonary TB on a six-month treatment regimen in Kampala, Uganda.

Methods

We retrieved data (January 2012 and December 2021) across six TB clinics in the Kampala Metropolitan area for all previously treated persons with bacteriologically confirmed pulmonary TB. TSR was defined as cure or treatment completion. Frequencies and percentages for categorical data, and the mean and standard deviation for numerical data were computed. Multivariable modified Poisson regression analysis was performed to identify factors associated with TSR, reported as adjusted risk ratio (aRR) with a 95% confidence interval (CI).

Measurements and main results

We enrolled 230 participants with a mean age of 34.8±10.6 years. TSR was 52.2% and was associated with Mycobacterium tuberculosis (MTB) sputum smear load of ≥2+ (1-10 or >10 Acid Fast Bacilli (AFB)/Field) (aRR = 0.51; 95% CI, 0.38-0.68), TB/human immunodeficiency virus (HIV) (aRR = 0.67; 95% CI, 0.51-0.88) or unknown HIV serostatus (aRR = 0.42; 95% CI, 0.26-0.68), and digital community-based directly observed therapy short-course (DOTS) (aRR = 0.42; 95% CI, 0.20-0.88).

Conclusions

The TSR among previously treated persons with bacteriologically confirmed pulmonary TB on a six-month treatment regimen is suboptimal. TSR is less likely for people with TB/HIV co-infection or unknown HIV serostatus, high MTB sputum smear load, and on digital community-based DOTs. We recommend strengthening of TB/HIV collaborative activities and people with TB with high MTB sputum smear load should receive targeted treatment support, and the contextual barriers to digital community DOTS should be addressed.

Role of NF-κB during Mycobacterium tuberculosis Infection

Mycobacterium tuberculosis (M. tb) causes tuberculosis infection in humans worldwide, especially among immunocompromised populations and areas of the world with insufficient funding for tuberculosis treatment. Specifically, M. tb is predominantly exhibited as a latent infection, which poses a greater risk of reactivation for infected individuals. It has been previously shown that M. tb infection requires pro-inflammatory and anti-inflammatory mediators to manage its associated granuloma formation via tumor necrosis factor-α (TNF-α), interleukin-12 (IL-12), interferon-γ (IFN-γ), and caseum formation via IL-10, respectively. Nuclear factor κ-light-chain-enhancer of activated B cells (NF-κB) has been found to play a unique mediator role in providing a pro-inflammatory response to chronic inflammatory disease processes by promoting the activation of macrophages and the release of various cytokines such as IL-1, IL-6, IL-12, and TNF-α. NF-κB's role is especially interesting in its mechanism of assisting the immune system's defense against M. tb, wherein NF-κB induces IL-2 receptors (IL-2R) to decrease the immune response, but has also been shown to crucially assist in keeping a granuloma and bacterial load contained. In order to understand NF-κB's role in reducing M. tb infection, within this literature review we will discuss the dynamic interaction between M. tb and NF-κB, with a focus on the intracellular signaling pathways and the possible side effects of NF-κB inactivation on M. tb infection. Through a thorough review of these interactions, this review aims to highlight the role of NF-κB in M. tb infection for the purpose of better understanding the complex immune response to M. tb infection and to uncover further potential therapeutic methods.