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Subbaraman R, Thomas BE, Kumar JV, Thiruvengadam K, Khandewale A, Kokila S, Lubeck-Schricker M, Ranjith Kumar M, Gaurkhede GR, Walgude AS, Hephzibah Mercy J, Kumbhar JD, Eliasziw M, Mayer KH, Haberer JE. Understanding Nonadherence to Tuberculosis Medications in India Using Urine Drug Metabolite Testing: A Cohort Study. Open Forum Infect Dis 2021; 8:ofab190. [PMID: 34250181 PMCID: PMC8262681 DOI: 10.1093/ofid/ofab190] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/13/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Poor adherence to tuberculosis (TB) treatment is associated with disease recurrence and death. Little research has been conducted in India to understand TB medication nonadherence. METHODS We enrolled adult drug-susceptible TB patients, approximately half of whom were people with human immunodeficiency virus (PWH), in Chennai, Vellore, and Mumbai. We conducted a single unannounced home visit to administer a survey assessing reasons for nonadherence and collect a urine sample that was tested for isoniazid content. We described patient-reported reasons for nonadherence and identified factors associated with nonadherence (ie, negative urine test) using multivariable logistic regression. We also assessed the association between nonadherence and treatment outcomes. RESULTS Of 650 participants in the cohort, 77 (11.8%) had a negative urine test. Nonadherence was independently associated with daily wage labor (adjusted odds ratio [aOR], 2.7; confidence interval [CI], 1.1-6.5; P = .03), the late continuation treatment phase (aOR, 2.0; CI, 1.1-3.9; P = .03), smear-positive pulmonary disease (aOR, 2.1; CI, 1.1-3.9; P = .03), alcohol use (aOR, 2.5; CI, 1.2-5.2; P = .01), and spending ≥30 minutes collecting medication refills (aOR, 6.6; CI, 1.5-29.5; P = .01). People with HIV reported greater barriers to collecting medications than non-PWH. Among 167 patients reporting missing doses, reported reasons included traveling from home, forgetting, feeling depressed, and running out of pills. The odds of unfavorable treatment outcomes were 4.0 (CI, 2.1-7.6) times higher among patients with nonadherence (P < .0001). CONCLUSION Addressing structural and psychosocial barriers will be critical to improve TB treatment adherence in India. Urine isoniazid testing may help identify nonadherent patients to facilitate early intervention during treatment.
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Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts
University School of Medicine, Boston,
Massachusetts, USA
- Division of Geographic Medicine and Infectious Diseases,
Tufts Medical Center, Boston,
Massachusetts, USA
| | - Beena E Thomas
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
- Correspondence: Beena E. Thomas, PhD, MSW, Department of Social and
Behavioural Research, ICMR- National Institute for Research in Tuberculosis, No.
1, Mayor Sathiyamoorthy Road, Chetpet, Chennai – 600 031, India ()
| | - J Vignesh Kumar
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - Kannan Thiruvengadam
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - Amit Khandewale
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - S Kokila
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - Maya Lubeck-Schricker
- Department of Public Health and Community Medicine, Tufts
University School of Medicine, Boston,
Massachusetts, USA
| | - M Ranjith Kumar
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - Gunjan Rahul Gaurkhede
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - Apurva Shashikant Walgude
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - J Hephzibah Mercy
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - Jagannath Dattatraya Kumbhar
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - Misha Eliasziw
- Department of Public Health and Community Medicine, Tufts
University School of Medicine, Boston,
Massachusetts, USA
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health and Department of
Medicine, Beth Israel Deaconess Medical Center and Harvard Medical
School, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital
and Department of Medicine, Harvard Medical School,
Boston, Massachusetts, USA
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