Health care seeking patterns of rifampicin-resistant tuberculosis patients in Harare, Zimbabwe: A prospective cohort study.

Collins Timire,Rebecca Tadokera,Grant Theron,John Z Metcalfe,Salome Manyau-Makumbirofa,Stella Huo

doi:10.1371/journal.pone.0254204

Abstract

Delays in seeking and accessing treatment for rifampicin-resistant tuberculosis (RR-TB) and multi-drug resistant (MDR-TB) are major impediments to TB control in high-burden, resource-limited settings. We prospectively determined health-seeking behavioural patterns and associations with treatment outcomes and costs among 68 RR-TB patients attending conveniently selected facilities in a decentralised system in Harare, Zimbabwe. From initial symptoms to initiation of effective treatment, patients made a median number of three health care visits (IQR 2-4 visits) at a median cost of 13% (IQR 6-31%) of their total annual household income (mean cost, US$410). Cumulatively, RR-TB patients most frequently first visited private facilities, i.e., private pharmacies (30%) and other private health care providers (24%) combined. Median patient delay was 26 days (IQR 14-42 days); median health system delay was 97 days (IQR 30-215 days) and median total delay from symptom onset to initiation of effective treatment was 132 days (IQR 51-287 days). The majority of patients (88%) attributed initial delay in seeking care to "not feeling sick enough." Total delay, total cost and number of health care visits were not associated with treatment or clinical outcomes, though our study was not adequately powered for these determinations. Despite the public availability of rapid molecular TB tests, patients experienced significant delays and high costs in accessing RR-TB treatment. Active case finding, integration of private health care providers and enhanced service delivery may reduce treatment delay and TB associated costs.

Highlights

Multi-drug resistant (MDR) tuberculosis (TB) remains a public health crisis and health security threat [1]
From initial symptoms to initiation of effective treatment, patients made a median number of three health care visits (IQR 2–4 visits) at a median cost of 13% (IQR 6–31%) of their total annual household income
The social and economic burden associated with TB and MDR-TB treatment [2], compounded by the HIV epidemic, places a disproportionate burden of disease on SubSaharan African countries [3, 4]

Summary

Introduction

Multi-drug resistant (MDR) tuberculosis (TB) remains a public health crisis and health security threat [1]. For MDR-TB, timing delays can significantly determine treatment outcomes and are likely to increase the infectiousness and disease transmission in a community [4]. The resultant delays to diagnosis and effective treatment related to health system weaknesses are further informed by patient choices and behaviour [8]. Such delays increase community transmission and may worsen treatment outcomes [9]. Delays in seeking and accessing treatment for rifampicin-resistant tuberculosis (RR-TB) and multi-drug resistant (MDR-TB) are major impediments to TB control in high-burden, resource-limited settings.

Methods

Results

Conclusion