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Treatment outcomes for multidrug-resistant tuberculosis (MDR-TB) in South Africa have suffered as centralized, in-patient treatment programs struggle to cope with rising prevalence and human immunodeficiency virus (HIV) co-infection rates. A new treatment model is needed to expand treatment capacity and improve MDR-TB and HIV outcomes.
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Context in source publication
Context 1
... newly diagnosed with MDR-TB are traced and evaluated at the decentralized MDR- TB clinic within one week. All patients receive a baseline history; physical exam; chest x- ray; audiometry; blood work for hematology, chemistry and liver function tests; repeat sputum culture and drug-susceptibility testing; HIV testing; and if HIV co-infected, CD4 count and viral load (Figure 1). In accordance with South African national treatment guidelines, all patients receive a standardized MDR-TB regimen (kanamycin, ofloxacin, cycloserine, ethionamide, pyrazinamide and ethambutol [if known to be ethambutol- sensitive]), and if HIV co-infected, a first-line ARV regimen (efavirenz, lamivudine, and stavudine [tenofovir replaced stavudine as of April 2010]). ...
Citations
... The axiom of 'one patient, one folder, and one HCW' remained elusive for most patients despite its advantages of promoting efficiency within the health system in delivering cost effective services and providing opportunities for managing drug interactions and adverse reactions. 37,38 For effectiveness, rather than using a 'silo' approach to patient care where each condition is managed vertically, a combined vertical and horizontal approach to patient management would be potentially more cost effective for both the patient and care providers. However, this may require re-organisation of the health system, a mind-set shift, and retraining or upskilling of HCWs. ...
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.
... In this study, a dedicated team of community health workers and nurses were trained to administer ART and comprehensive MDR-TB treatment in individuals' homes in hopes of eliminating mechanical and financial barriers to receiving treatment. Following treatment, a brief questionnaire regarding symptoms and side effects was administered, and more severe cases were brought to the clinic for immediate evaluation (68). This proved to be a promising model for delivering care to remote areas with a high prevalence of disease and boasted an impressively low mortality rate. ...
Mycobacterium tuberculosis ( Mtb ) is the causative agent of tuberculosis (TB) in humans, Although Mtb is primarily considered a respiratory pathogen, its ability to spread to and affect the central nervous system (CNS) is of particular interest due to its clinical importance. Tuberculosis meningitis (TBM) is described as the manifestation of Mtb infection in the meninges, leading to inflammation and disease. Individuals with a weakened immune system, particularly those infected with human immunodeficiency virus (HIV), are more susceptible to both pulmonary and extrapulmonary Mtb infection. HIV infection leads to a gradual depletion of CD4 T-cells, severely impairing the host's immune response against pathogens and, thus, predisposes one to several opportunistic infections, including Mtb . Herein, we discuss the current knowledge, potential therapeutic agents, and mechanisms of action and describe various in vivo and in vitro models that may be used to study TBM coexisting with HIV infection.
... Decentralised TB care to connect health workers and patients. Brust et al.'s study implemented an integrated home-based treatment model for DR-TB and HIV as patient-centred care [38]. Among the 67 (84%) patients who completed the intensive phase of treatment, all had converted their sputum culture to negative in a median of 55 days. ...
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.
... Tuberculosis (TB) is nearly always curable if patients are treated with effective uninterrupted anti-tuberculosis therapy. Adherence to treatment is critical for cure of individual patients, controlling the spread of infection and minimizing the development of drug resistance [12] [13]. Re treatment of TB or treatment of multi-drug resistant TB is far more complicated and expensive. ...
Background: The prevalence and incidence rate of tuberculosis remains high although the disease is known to be almost always curable provided the patient adheres to the treatment regimen. This study assessed the strength of association between known patient and health system factors associated with first line tuberculosis treatment adherence. Methods: A quantitative cross sectional study. Retrospective chart reviews were conducted among 570 persons who had primary tuberculosis and received first line treatment at a health facility within the Nkangala district, Mpumalanga province and who had a treatment outcome recorded between 1st January 2009 and 31st De-cember 2014. Adherence to first line tuberculosis treatment was defined as taking ≥80% of tuberculosis prescribed drugs within a period of 6 to 8 months. Stata software (logistic regressions model) was used to analyze results and find the strength of association between known factors and treatment adherence. Results: Out of the 570 study participants, 473 were adherent and 96 were not adherent. There was a statistically significant association between age 18 years and above (OR: 1.02, P-value: 0.027), sex (lower in males OR: 0.44, P-value: 0.001) and support (OR: 3.04, P-value: 0.05) and HIV (OR: 1, P-value: 0.634) and first line TB treatment adherence. Conclusion and Recommendation: >80% adherence to first line tuberculosis outcome is possible. The support given to people with tuberculosis will further enhance adherence to first line tuberculosis treatment.
... Similarly, a quasi-experimental study done in India showed that home-based care was associated with low stigma [26] similar to our study findings. In rural South Africa, MDR-TB patients preferred to receive MDR-TB and HIV care at home, and this was associated with reduced levels of rejection creating strong emotional bonds between patients, families and communities that is critical to health [27]. The home is seen as a place conducive for recovery and offers both psychological and emotional support needed to enable healing [28]. ...
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.
... Tuberculosis (TB) is nearly always curable if patients are treated with effective uninterrupted anti-tuberculosis therapy. Adherence to treatment is critical for cure of individual patients, controlling the spread of infection and minimizing the development of drug resistance [12] [13]. Re treatment of TB or treatment of multi-drug resistant TB is far more complicated and expensive. ...
Background: The prevalence and incidence rate of tuberculosis remains high although the disease is known to be almost always curable provided the patient adheres to the treatment regimen. This study assessed the strength of association between known patient and health system factors associated with first line tuberculosis treatment adherence.
Methods: A quantitative cross-sectional study. Retrospective chart reviews were conducted among 570 persons who had primary tuberculosis and received first line treatment at a health facility within the Nkangala district, Mpumalanga province and who had a treatment outcome recorded between 1st January 2009 and 31st December 2014. Adherence to first line tuberculosis treatment was defined as taking ≥80% of tuberculosis prescribed drugs within a period of 6 to 8 months. Stata software (logistic regressions model) was used to analyze results and find the strength of association between known factors and treatment adherence.
Results: Out of the 570 study participants, 473 were adherent and 96 were not adherent. There was a statistically significant association between age 18 years and above (OR: 1.02, P-value: 0.027), sex (lower in males OR: 0.44, P-value: 0.001) and support (OR: 3.04, P-value: 0.05) and HIV (OR: 1, P-value: 0.634) and first line TB treatment adherence.
Conclusion and Recommendation: >80% adherence to first line tuberculosis outcome is possible. The support given to people with tuberculosis will further enhance adherence to first line tuberculosis treatment.
... There is considerable research in other countries that emphasizes novel approaches toward TB patient management. In South Africa, Brust and colleagues implemented an integrated home-based MDR-TB-HIV treatment program and tried to decentralized care for patients [22]. There is another research in Ghana, and this study sought additional activities for the further improvement of patient management [23]. ...
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.
... Generally, majority of the participants indicated that utilization of Minimum HBCP essential package by stakeholders that is Provision of Psycho-social services, Provision of Spiritual Support caregivers, Provision of Physical support equipment and aids, Provision of Legal support services, Provision of Nursing care services, Provision of Clinical services, Health information management systems, Health education and promotion were at 44.1% never used. This is an indicator that there was overall poor utilization of minimum HBCP essential package by caregivers of chronically and terminally ill Children as per empirical study by Goodson et al. [20], Brust et al. [4] and Brust et al. [5]. ...
Introduction: Worldwide, 57 million people died in 2008 from Chronic Illnesses, an estimated 40 million were in need of HBCP services with 6.6 - 10.8 million Children and adolescents dying [1,2]. 98% of Children with Chronic and Terminal illnesses (CI/TI) are found in low and middle-income Countries. Chronic and Terminal illnesses in Children are on the rise in Sub Saharan Africa. Kenya has lagged in implementation of Home Based Care to mitigate effects of CI/TI [3]. According to WHO, 2017 and Ministry of Health-Kenya 2013, millions of Children are affected by these Illnesses such as Tuberculosis, Asthma, Congenital abnormalities, HIV/AIDS and Cancer among others [4,5]. These illnesses have made families’ to suffer emotional, psychosocial and economic hardships [6,7]. Evaluation of utilization of Home Based Care Program (EHBCP) services is significant in assessing effectiveness and quality delivery of HBCP [8,9]. Aims: To assess usage of minimum essential package required in provision of Home Based Care program services for Children aged between 1-14 years diagnosed with selected Chronic and Terminal illnesses in Meru County Kenya. Study Design: A descriptive Cross Sectional Survey. Place and Duration of Study: Conducted in Meru County Kenya Health facilities between June 2018 and Dec 2019. Methodology: Descriptive Cross Sectional Survey of 245 Health Care Providers and Caregivers of Children diagnosed with selected by proportionate to size sampling and simple random sampling from different health facilities across Meru County was utilized. Results: Utilization, delivery of quality and effective Home Based Care program was positively associated with age, experience of Health Care Workers (HCWs) 4.8 [95% CI = 1.06 – 21.68, P = 0.041]. HCWs profession, gender and years of work were positively related to utilization and delivery of HBCP services 3.03 [95%CI = 1.64 – 5.59, P<0.001]. Conclusion: Current study concludes that utilization of Minimum HBCP essential package by participants was not effective and the quality delivery of minimum HBCP essential services was inadequate, which agrees with Sips et al., 2014 study that poor service delivery leads to inadequate utilization, it concludes that restructuring HBCP services would meet individual needs for ill Children.
... Generally, majority of the participants indicated that utilization of Minimum HBCP essential package by stakeholders that is Provision of Psycho-social services, Provision of Spiritual Support caregivers, Provision of Physical support equipment and aids, Provision of Legal support services, Provision of Nursing care services, Provision of Clinical services, Health information management systems, Health education and promotion were at 44.1% never used. This is an indicator that there was overall poor utilization of minimum HBCP essential package by caregivers of chronically and terminally ill Children as per empirical study by Goodson et al. [20], Brust et al. [4] and Brust et al. [5]. ...
Public Health Interventions for Children with chronically & Terminally ill children have been left out, Therefore assessment of HBCP was vital.
... 30 Decentralising DRTB treatment to facilities closer to patients' homes could ultimately settle many reported difficulties, and all-oral regimens facilitate the expansion of previously implemented community-based and homebased approaches. 3,[31][32][33] To succeed, a resourced and supportive environment is needed in patients' homes (dedicated living space, food security, adherence aids, and an informed, empathetic household) and within patients' community (providers with strong clinical and communication skills, opportunities for income generation, and awareness about DRTB recovery and not just risk). Making space for some patient choice and differentiated care, commonly promoted within HIV programmes and recently postulated for tuberculosis, 34 could meet the needs of patients who are clinically stable, resourced, and adapted to treatment, diverting attention to those with greater needs and challenges. ...
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.
