Abstract
BACKGROUND AND OBJECTIVES: Patients with MDR-TB in remote areas of Haiti face barriers that delay their ability to initiate and complete treatment. These barriers must be addressed to ensure successful decentralization of MDR-TB treatment. We conducted a mixed-methods study at two MDR-TB facilities in rural Haiti to identify factors that impact MDR-TB treatment initiation and documented treatment response after discharge from hospital. 
 
 METHODS: We enrolled patients who started MDR-TB treatment at two Zanmi Lasante MDR-TB facilities in Haiti between October 2015 and March 2016. We conducted interviews with patients at discharge to assess factors creating delay in treatment initiation; performed a longitudinal quantitative assessment of patient wellbeing at discharge and for four months after; and conducted a second interview with the same patients and family caregivers to identify obstacles to transition from hospital-based care to ambulatory treatment. Qualitative data were coded into six final conceptual categories representing patient experiences with TB treatment and care. We then explored how the patient experience during transition might affect the score obtained in the quantitative assessment.
 
 RESULTS: We enrolled 17 MDR-TB patients and 16 family members. Four patients were identified as having poor clinical response after discharge, characterized by low BMI, low hemoglobin, compromised activities of daily life, food insecurity, depression and other treatment side effects. Patients with poor response also experienced limited social support and difficult living conditions.
 
 Factors contributing to delayed treatment initiation were present at discharge and may compromise response. These include financial (lost wages, costly transportation) and logistical barriers to reaching highly centralized treatment facilities. The results highlight the barriers that MDR-TB patients in rural Haiti face to find and successfully complete lifesaving treatment. 
 
 CONCLUSION: Properly implemented decentralized care will help overcome geographical barriers. Strong nutritional, social and financial support are essential to support appropriate treatment for the disease.
Highlights
In February 2012, Alfred Simon (Note 1), a 26 year-old peasant farmer living in a remote area of Haiti, reported several months of night sweats, coughing and weight loss at a local health center and was diagnosed with tuberculosis (TB)
Four patients were identified as having poor clinical response after discharge, characterized by low Body Mass Index (BMI), low hemoglobin, compromised activities of daily life, food insecurity, depression and other treatment side effects
All patients enrolled for multidrug-resistant TB (MDR-TB) treatment during the study period agreed and were eligible to participate in the study
Summary
In February 2012, Alfred Simon (Note 1), a 26 year-old peasant farmer living in a remote area of Haiti, reported several months of night sweats, coughing and weight loss at a local health center and was diagnosed with tuberculosis (TB). Patients with MDR-TB in remote areas of Haiti face barriers that delay their ability to initiate and complete treatment. These barriers must be addressed to ensure successful decentralization of MDR-TB treatment. We conducted a mixed-methods study at two MDR-TB facilities in rural Haiti to identify factors that impact MDR-TB treatment initiation and documented treatment response after discharge from hospital. In Haiti, MDR-TB is estimated to occur in 2.9% of new cases and in 13% of patients previously treated for TB (WHO, 2017b). Undiagnosed and untreated drug-resistant TB (DR-TB) cases are very dangerous for the community (Institute of Medicine [IOM], 2011), treatment is often considered too expensive to be cost-effective in resource-poor settings (Iseman, Cohn, & Sbarbaro, 1993; White & Moore-Gillon, 1998)
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