Abstract
SummaryBackgroundIndirect financial costs and barriers to health-care access might contribute to leprosy treatment non-adherence. We estimated the association of the Brazilian conditional cash transfer programme, the Programa Bolsa Família (PBF), on leprosy treatment adherence and cure in patients in Brazil.MethodsIn this quasi-experimental study, we linked baseline demographic and socioeconomic information for individuals who entered the 100 Million Brazilian Cohort between Jan 1, 2007, and Dec 31, 2014, with the PBF payroll database and the Information System for Notifiable Diseases, which includes nationwide leprosy registries. Individuals were eligible for inclusion if they had a household member older than 15 years and had not received PBF aid or been diagnosed with leprosy before entering the 100 Million Brazilian Cohort; they were excluded if they were partial receivers of PBF benefits, had missing data, or had a monthly per-capita income greater than BRL200 (US$50). Individuals who were PBF beneficiaries before leprosy diagnosis were matched to those who were not beneficiaries through propensity-score matching (1:1) with replacement on the basis of baseline covariates, including sex, age, race or ethnicity, education, work, income, place of residence, and household characteristics. We used logistic regression to assess the average treatment effect on the treated of receipt of PBF benefits on leprosy treatment adherence (six or more multidrug therapy doses for paucibacillary cases or 12 or more doses for multibacillary cases) and cure in individuals of all ages. We stratified our analysis according to operational disease classification (paucibacillary or multibacillary). We also did a subgroup analysis of paediatric leprosy restricted to children aged up to 15 years.FindingsWe included 11 456 new leprosy cases, of whom 8750 (76·3%) had received PBF before diagnosis and 2706 (23·6%) had not. Overall, 9508 (83·0%) patients adhered to treatment and 10 077 (88·0%) were cured. After propensity score matching, receiving PBF before diagnosis was associated with adherence to treatment (OR 1·22, 95% CI 1·01–1·48) and cure (1·26, 1·01–1·58). PBF receipt did not significantly improve treatment adherence (1·37, 0·98–1·91) or cure (1·12, 0·75–1·67) in patients with paucibacillary leprosy. For patients with multibacillary disease, PBF beneficiaries had better treatment adherence (1·37, 1·08–1·74) and cure (1·43, 1·09–1·90) than non-beneficiaries. In the propensity score-matched analysis in 2654 children younger than 15 years with leprosy, PBF exposure was not associated with leprosy treatment adherence (1·55, 0·89–2·68) or cure (1·57, 0·83–2·97).InterpretationOur results suggest that being a beneficiary of the PBF, which facilitates cash transfers and improved access to health care, is associated with greater leprosy multidrug therapy adherence and cure in multibacillary cases. These results are especially relevant for patients with multibacillary disease, who are treated for a longer period and have lower cure rates than those with paucibacillary disease.FundingCONFAP/ESRC/MRC/BBSRC/CNPq/FAPDF–Doenças Negligenciadas, the UK Medical Research Council, the Wellcome Trust, and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior–Brazil (CAPES).
Highlights
Leprosy, known as Hansen’s disease, is a neglected tropical disease that affects more than 200 000 individuals worldwide annually and is a leading infectious cause of permanent physical disability.[1,2] As the burden of leprosy-associated disability can be mitigated through timely detection and treatment, WHO has supplied free multidrug therapy to health systems in high-burden countries since 1995.1 WHO recommends a 6-month treatment regimen for patients with paucibacillary leprosy, comprising daily doses of dapsone.[1]
We found 628 records and identified only two relevant studies that evaluated any associations between receiving social protection benefits and leprosy incidence, prevalence, related disabilites, and treatment outcomes
Using a causal inference framework of analysis and propensity score methods to control for socioeconomic and demographic characteristics, we found that receiving Programa Bolsa Família (PBF) benefits was associated with improved adherence to multidrug therapy treatment and increased cure rates
Summary
Known as Hansen’s disease, is a neglected tropical disease that affects more than 200 000 individuals worldwide annually and is a leading infectious cause of permanent physical disability.[1,2] As the burden of leprosy-associated disability can be mitigated through timely detection and treatment, WHO has supplied free multidrug therapy to health systems in high-burden countries since 1995.1 WHO recommends a 6-month treatment regimen for patients with paucibacillary leprosy (ie, those with five lesions or fewer), comprising daily doses of dapsone.[1]. We found 628 records and identified only two relevant studies that evaluated any associations between receiving social protection benefits and leprosy incidence, prevalence, related disabilites, and treatment outcomes. Both studies had an ecological design and evaluated the association between the conditional cash transfer programme Programa Bolsa Família (PBF) and leprosy incidence in Brazil at the municipality level. Both studies found an approximately 15% reduced leprosy incidence in municipalities with high coverage of PBF, but neither evaluated its effect on treatment adherence or cure
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