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Tadesse AW, Mganga A, Dube TN, Alacapa J, van Kalmthout K, Letta T, Mleoh L, Garfin AMC, Maraba N, Charalambous S, Foster N, Jerene D, Fielding KL. Feasibility and acceptability of the smart pillbox and medication label with differentiated care to support person-centered tuberculosis care among ASCENT trial participants - A multicountry study. Front Public Health 2024; 12:1327971. [PMID: 38444445 PMCID: PMC10913790 DOI: 10.3389/fpubh.2024.1327971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/15/2024] [Indexed: 03/07/2024] Open
Abstract
Introduction Digital adherence technologies (DATs) can offer alternative approaches to support tuberculosis treatment medication adherence. Evidence on their feasibility and acceptability in high TB burden settings is limited. We conducted a cross-sectional survey among adults with drug-sensitive tuberculosis (DS-TB), participating in pragmatic cluster-randomized trials for the Adherence Support Coalition to End TB project in Ethiopia (PACTR202008776694999), the Philippines, South Africa and Tanzania (ISRCTN 17706019). Methods From each country we selected 10 health facilities implementing the DAT intervention (smart pillbox or medication labels, with differentiated care support), ensuring inclusion of urban/rural and public/private facilities. Adults on DS-TB regimen using a DAT were randomly selected from each facility. Feasibility of the DATs was assessed using a standardized tool. Acceptability was measured using a 5-point Likert-scale, using the Capability, Opportunity, Motivation, Behavior (COM-B) model. Mean scores of Likert-scale responses within each COM-B category were estimated, adjusted for facility-level clustering. Data were summarized by country and DAT type. Results Participants using either the pillbox (n = 210) or labels (n = 169) were surveyed. Among pillbox users, phone ownership (79%), use of pillbox reminders (87%) and taking treatment without the pillbox (22%) varied by country. Among label users, phone ownership (81%), paying extra to use the labels (8%) and taking treatment without using labels (41%) varied by country. Poor network, problems with phone charging and access, not having the pillbox and forgetting to send text were reasons for not using DATs. Overall, people with TB had a favorable impression of both DATs, with mean composite scores between 4·21 to 4·42 across COM-B categories. Some disclosure concerns were reported. Conclusion From client-perspective, pillboxes and medication labels with differentiated care support were feasible to implement and acceptable in variety of settings. However, implementation challenges related to network, phone access, stigma, additional costs to people with TB to use DATs need to be addressed.
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Affiliation(s)
- Amare W. Tadesse
- TB Centre, Department of Infectious Disease Epidemiology and International Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | | | - Tanyaradzwa N. Dube
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | | | | | - Taye Letta
- National Tuberculosis Control Program, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Liberate Mleoh
- National Tuberculosis Control Program, Ministry of Health, Dodoma, Tanzania
| | - Anna M. C. Garfin
- National Tuberculosis Control Program, Department of Health, Manila, Philippines
| | - Noriah Maraba
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Salome Charalambous
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Nicola Foster
- TB Centre, Department of Infectious Disease Epidemiology and International Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Degu Jerene
- Evidence and Impact, KNCV Tuberculosis Plus, The Hague, Netherlands
| | - Katherine L. Fielding
- TB Centre, Department of Infectious Disease Epidemiology and International Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Jerene D, Levy J, van Kalmthout K, Rest JV, McQuaid CF, Quaife M, Charalambous S, Gamazina K, Garfin AMC, Mleoh L, Terleieva Y, Bogdanov A, Maraba N, Fielding K. Effectiveness of digital adherence technologies in improving tuberculosis treatment outcomes in four countries: a pragmatic cluster randomised trial protocol. BMJ Open 2023; 13:e068685. [PMID: 36918242 PMCID: PMC10016242 DOI: 10.1136/bmjopen-2022-068685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Successful treatment of tuberculosis depends to a large extent on good adherence to treatment regimens, which relies on directly observed treatment (DOT). This in turn requires frequent visits to health facilities. High costs to patients, stigma and burden to the health system challenged the DOT approach. Digital adherence technologies (DATs) have emerged as possibly more feasible alternatives to DOT but there is conflicting evidence on their effectiveness and feasibility. Our primary objective is to evaluate whether the implementation of DATs with daily monitoring and a differentiated response to patient adherence would reduce poor treatment outcomes compared with the standard of care (SOC). Our secondary objectives include: to evaluate the proportion of patients lost to follow-up; to compare effectiveness by DAT type; to evaluate the feasibility and acceptability of DATs; to describe factors affecting the longitudinal engagement of patients with the intervention and to use a simple model to estimate the epidemiological impact and cost-effectiveness of the intervention from a health system perspective. METHODS AND ANALYSIS This is a pragmatic two-arm cluster-randomised trial in the Philippines, South Africa, Tanzania and Ukraine, with health facilities as the unit of randomisation. Facilities will first be randomised to either the DAT or SOC arm, and then the DAT arm will be further randomised into medication sleeve/labels or smart pill box in a 1:1:2 ratio for the smart pill box, medication sleeve/label or the SOC respectively. We will use data from the digital adherence platform and routine health facility records for analysis. In the main analysis, we will employ an intention-to-treat approach to evaluate treatment outcomes. ETHICS AND DISSEMINATION The study has been approved by the WHO Research Ethics Review Committee (0003296), and by country-specific committees. The results will be shared at national and international meetings and will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN17706019.
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Affiliation(s)
- Degu Jerene
- Division of Tuberculosis Elimination and Health Systems Strengthening, KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Jens Levy
- Division of Tuberculosis Elimination and Health Systems Strengthening, KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Kristian van Kalmthout
- Division of Tuberculosis Elimination and Health Systems Strengthening, KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Job van Rest
- Division of Tuberculosis Elimination and Health Systems Strengthening, KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Christopher Finn McQuaid
- TB Centre and Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew Quaife
- TB Centre and Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Katya Gamazina
- Program for Appropriate Technology in Health, Kyiv, Ukraine
| | - A M Celina Garfin
- Department of Health, Infectious Diseases Prevention and Control Division, Disease Prevention and Control Bureau, Manila, the Philippines
| | - Liberate Mleoh
- Department of Preventive Services, National Tuberculosis and Leprosy Programme, Dodoma, United Republic of Tanzania
| | - Yana Terleieva
- Department of Coordination of TB Treatment Programs, Kyiv, Ukraine
| | | | | | - Katherine Fielding
- TB Centre and Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Mleoh L, Mziray SR, Tsere D, Koppelaar I, Mulder C, Lyakurwa D. Shorter regimens improved treatment outcomes of multidrug-resistant tuberculosis patients in Tanzania in 2018 cohort. Trop Med Int Health 2023; 28:357-366. [PMID: 36864011 DOI: 10.1111/tmi.13867] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
OBJECTIVE In 2018, shorter treatment regimens (STR) for people with drug-resistant tuberculosis (DR-TB) were introduced in Tanzania and included kanamycin, high-dose moxifloxacin, prothionamide, high-dose isoniazid, clofazimine, ethambutol and pyrazinamide. We describe treatment outcomes of people diagnosed with DR-TB in a cohort initiating treatment in 2018 in Tanzania. METHODS This was a retrospective cohort study conducted at the National Centre of Excellence and decentralised DR-TB treatment sites for the 2018 cohort followed from January 2018 to August 2020. We reviewed data from the National Tuberculosis and Leprosy Program DR-TB database to assess clinical and demographic information. The association between different DR-TB regimens and treatment outcome was assessed using logistic regression analysis. Treatment outcomes were described as treatment complete, cure, death, failure or lost to follow-up. A successful treatment outcome was assigned when the patient achieved treatment completion or cure. RESULTS A total of 449 people were diagnosed with DR-TB of whom 382 had final treatment outcomes: 268 (70%) cured; 36 (9%) treatment completed; 16 (4%) lost to follow-up; 62 (16%) died. There was no treatment failure. The treatment success rate was 79% (304 patients). The 2018 DR-TB treatment cohort was initiated on the following regimens: 140 (46%) received STR, 90 (30%) received the standard longer regimen (SLR), 74 (24%) received a new drug regimen. Normal nutritional status at baseline [adjusted odds ratio (aOR) = 6.57, 95% CI (3.33-12.94), p < 0.001] and the STR [aOR = 2.67, 95% CI (1.38-5.18), p = 0.004] were independently associated with successful DR-TB treatment outcome. CONCLUSION The majority of DR-TB patients on STR in Tanzania achieved a better treatment outcome than on SLR. The acceptance and implementation of STR at decentralised sites promises greater treatment success. Assessing and improving nutritional status at baseline and introducing new shorter DR-TB treatment regimens may strengthen favourable treatment outcomes.
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Affiliation(s)
- Liberate Mleoh
- National Tuberculosis and Leprosy Program, Ministry of Health, Dodoma, Tanzania
| | - Shabani Ramadhani Mziray
- Kibong'oto Infectious Diseases Hospital, Kilimanjaro, Tanzania.,Department of Biochemistry and Molecular Biology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Donatus Tsere
- Kibong'oto Infectious Diseases Hospital, Kilimanjaro, Tanzania
| | - Inge Koppelaar
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Christiaan Mulder
- KNCV Tuberculosis Foundation, The Hague, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Dennis Lyakurwa
- Department of Curative Services, Ministry of Health, Dodoma, Tanzania
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Kalolo A, Lalashowi J, Pamba D, Shayo PJ, Gitige C, Mvungi H, Ntagazwa W, Lekule I, Kisonga R, Mleoh L, John J, Kapologwe NA, Mutayoba B, Matechi E, Mpagama SG, Ntinginya NE. Implementation of the 'Removed Injectable modified Short-course regimens for EXpert Multidrug Resistant Tuberculosis' (RISE study) in Tanzania: a protocol for a mixed-methods process evaluation. BMJ Open 2022; 12:e054434. [PMID: 35613774 PMCID: PMC9131053 DOI: 10.1136/bmjopen-2021-054434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Tanzania is adapting a shortened injectable-free multidrug resistant tuberculosis (MDR-TB) regimen, comprising new drugs such as bedaquiline and delamanid and repurposed drugs such as clofazimine and linezolid. The regimen is implemented using a pragmatic prospective cohort study within the National TB and Leprosy Programme and is accompanied by a process evaluation. The process evaluation aims to unpack the implementation processes, their outcomes and the moderating factors in order to understand the clinical effectiveness of the regimen. This protocol describes the methods employed in understanding the implementation processes of the new MDR-TB regimen in 15 regions of Tanzania. METHODS This study adopts a concurrent mixed-methods design. Using multiple data collection tools, we capture information on: implementation outcomes, stakeholder response to the intervention and the influence of contextual factors. Data will be collected from the 22 health facilities categorised as dispensaries, health centres, district hospitals and referral hospitals. Health workers (n=132) and patients (n=220) will fill a structured questionnaire. For each category of health facility, we will conduct five focus group discussions and in-depth interviews (n=45) for health workers. Participant observations (n=9) and review documents (n=22) will be conducted using structured checklists. Data will be collected at two points over a period of 1 year. We will analyse quantitative data using descriptive and inferential statistical methods. Thematic analysis will be used for qualitative data. ETHICS AND DISSEMINATION This study received ethical approval from National Institute of Medical research (NIMR), Ref. NIMR/HQ/R.8a/Vol.IX/3269 and from the Mbeya Medical Research and Ethics Review Committee, Ref. SZEC-2439/R.A/V.I/38. Our findings are expected to inform the wider implementation of the new MDR-TB regimen as it is rolled out countrywide. Dissemination of findings will be through publications, conferences, workshops and implementation manuals for scaling up MDR-TB treatments.
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Affiliation(s)
- Albino Kalolo
- Department of Public Health, Saint Francis University College of Health and Allied Sciences, Ifakara, United Republic of Tanzania
- Implementation Research Division, Center for Reforms, Innovation, Health Policies and Implementation Research (CERIHI), Dodoma, United Republic of Tanzania
| | - Julieth Lalashowi
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | - Doreen Pamba
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | | | - Catherine Gitige
- Medical, Kibong'oto Infectious Diseases Hospital, Kilimanjaro, United Republic of Tanzania
| | - Happiness Mvungi
- Medical, Kibong'oto Infectious Diseases Hospital, Kilimanjaro, United Republic of Tanzania
| | - Webhale Ntagazwa
- National Tuberculosis and Leprosy Programme, Dodoma, United Republic of Tanzania
| | - Isaac Lekule
- National Tuberculosis and Leprosy Programme, Dodoma, United Republic of Tanzania
| | - Riziki Kisonga
- Medical, Kibong'oto Infectious Diseases Hospital, Kilimanjaro, United Republic of Tanzania
| | - Liberate Mleoh
- National Tuberculosis and Leprosy Programme, Dodoma, United Republic of Tanzania
| | - Johnson John
- National Tuberculosis and Leprosy Programme, Dodoma, United Republic of Tanzania
| | - Ntuli A Kapologwe
- Implementation Research Division, Center for Reforms, Innovation, Health Policies and Implementation Research (CERIHI), Dodoma, United Republic of Tanzania
- Department of Health, Social welfare and Nutrition Services, President's Office Regional Administration and Local Government (PORALG), Dodoma, United Republic of Tanzania
| | - Beatrice Mutayoba
- National AIDS Control Programme, Dodoma, United Republic of Tanzania
| | - Emmanuel Matechi
- National Tuberculosis and Leprosy Programme, Dodoma, United Republic of Tanzania
| | - Stellah G Mpagama
- Medical, Kibong'oto Infectious Diseases Hospital, Kilimanjaro, United Republic of Tanzania
| | - Nyanda Elias Ntinginya
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
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Lyakurwa D, Lyimo J, Mleoh L, Riziki K, Lupinda M, Mpondo BC. Successful treatment of XDR-TB patient in Tanzania: report of the first XDR-TB patient. Trop Doct 2019; 49:224-226. [PMID: 30885056 DOI: 10.1177/0049475519833554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Drug-resistant tuberculosis (TB) is emerging as a new and serious public health challenge. We present the first case with confirmed extensive drug-resistant TB in Tanzania in a patient who had prior exposure to anti-TB drugs and a history of imprisonment in South Africa. The addition of bedaquiline to the treatment regime resulted in positive to negative sputum conversion. After a total of 30 months on treatment he was declared cured, remaining clinically stable and culture-negative throughout the follow-up. Close monitoring is important in managing drug-resistant TB cases, and good surveillance is required to detect drug-resistant TB to prevent further transmission.
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Affiliation(s)
- Dennis Lyakurwa
- 1 Programmatic Management of Drug Resistant TB (PMDT) Technical Officer, KNCV Tuberculosis Foundation, Dar Es Salaam, Tanzania
| | - Johnson Lyimo
- 2 MDR-TB Coordinator - National TB and Leprosy Program, Ministry of Health of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania
| | - Liberate Mleoh
- 3 Deputy Program Manager-National TB and Leprosy Program, Ministry of Health of Health, Community Development, Gender, Elderly, and Children
| | - Kisonga Riziki
- 4 Hospital Director, Kibong'oto Infectious Disease Hospital, Sanya Juu Kilimanjaro
| | - Mrisho Lupinda
- 5 Regional TB and Leprosy coordinator - Kinondoni, Kinondoni Municipality Dar es Salaam region
| | - Bonaventura Ct Mpondo
- 6 Senior Lecturer, School of Medicine, College of Health Sciences, The University of Dodoma, Dodoma, Tanzania
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Semvua HH, Mtabho CM, Fillekes Q, van den Boogaard J, Kisonga RM, Mleoh L, Ndaro A, Kisanga ER, van der Ven A, Aarnoutse RE, Kibiki GS, Boeree MJ, Burger DM. Efavirenz, tenofovir and emtricitabine combined with first-line tuberculosis treatment in tuberculosis-HIV-coinfected Tanzanian patients: a pharmacokinetic and safety study. Antivir Ther 2012; 18:105-13. [PMID: 23043067 DOI: 10.3851/imp2413] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND To evaluate the effect of rifampicin-based tuberculosis (TB) treatment on the pharmacokinetics of efavirenz/tenofovir/emtricitabine in a fixed-dose combination tablet, and vice versa, in Tanzanian TB-HIV-coinfected patients. METHODS This was a Phase II open-label multiple dose pharmacokinetic and safety study. This study was conducted in TB-HIV-coinfected Tanzanian patients who started TB treatment (rifampicin/isoniazid/pyrazinamide/ethambutol) at week 1 to week 8 and continued with rifampicin and isoniazid for another 16 weeks. Antiretroviral treatment (ART) of efavirenz/tenofovir/emtricitabine in a fixed-dose combination tablet was started at week 4 after initiation of TB treatment. A 24-h pharmacokinetic sampling curve was recorded at week 8 (with TB treatment) and week 28 (ART alone). For TB drugs, blood samples at 2 and 5 h post-dose were taken at week 3 (TB treatment alone) and week 8 (with ART). RESULTS A total of 25 patients (56% male) completed the study; 21 had evaluable pharmacokinetic profiles. The area under the concentration-time curve 0-24 h post-dose of efavirenz, tenofovir and emtricitabine were slightly higher when these drugs were coadministered with TB drugs; geometric mean ratios (90% CI) were 1.08 (0.90, 1.30), 1.13 (0.93, 1.38) and 1.05 (0.85, 1.29), respectively. For TB drugs, equivalence was suggested for peak plasma concentrations when administered with and without efavirenz/tenofovir/emtricitabine. Adverse events were mostly mild and no serious adverse events or drug discontinuations were reported. CONCLUSIONS Coadministration of efavirenz, tenofovir and emtricitabine with a standard first-line TB treatment regimen did not significantly alter the pharmacokinetic parameters of these drugs and was tolerated well by Tanzanian TB patients who are coinfected with HIV.
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Affiliation(s)
- Hadija H Semvua
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania.
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