Tuberculosis Care Research Articles

A qualitative study to inform the development of a decision support tool for the diagnosis of pulmonary tuberculosis in Tigray, Ethiopia.

Tuberculosis (TB) is Ethiopia's leading infectious killer disease. The war in the Tigray region of Ethiopia has resulted in the disruption of TB care services. Prediction models are recommended to aid the diagnosis of TB in resource-limited settings. However, the development of such decision-support tools without the participation of end users may not be successful. To inform the tool development, we described barriers to diagnosing TB and identified applicable and desirable parameters for the proposed tool. We conducted a qualitative study between February and June 2023 in two cities in Tigray, Northern Ethiopia. We conducted 12 in-depth interviews and four focus group discussions with healthcare workers (HCWs). Interviews were translated, coded, and analyzed to identify predefined and emergent themes during the thematic analysis. Healthcare workers used symptoms, risk factors, signs, and investigations to diagnose TB. However, failure to ask about antibiotic use, the absence and non-affordability of investigations, and patient load were barriers affecting the diagnosis of TB. Most of the classic TB symptoms and their duration were sorted as very important, simple, reliable, generalizable, and desirable indices. In addition, a trial of antibiotics, being chronically sick-looking, having HIV, having a contact history with a TB patient, and an erythrocyte sedimentation rate fulfilled the above criteria. In the TB diagnostic process, HCWs account for a variety of data, but they prefer the classic symptoms of TB to heighten their clinical suspicion. Antibiotic trials and some risk factors were also considered reasonable. However, when HCWs have a heavy workload and a shortage of investigations, they experience a suboptimal TB diagnostic process. Hence, appropriate context consideration and care providers' preferences for parameters will inform tool development.

Private sector tuberculosis care quality during the COVID-19 pandemic: a repeated cross-sectional standardised patients study of adherence to national TB guidelines in urban Nigeria

Only a third of tuberculosis (TB) cases in Nigeria in 2020 were diagnosed and notified, in part due to low detection and under-reporting from the private health sector. Using a...

Out-of-pocket payment and catastrophic health expenditure of tuberculosis patients in accessing care at public-private mix clinics in Myanmar, 2022

BackgroundThe financial burden of tuberculosis (TB) can hinder patients and their families, creating obstacles throughout the care cascade, despite TB prevention and control being provided free of charge. In Myanmar, patients can visit private providers operating under public-private mix (PPM) schemes, where TB services (diagnosis and treatment) are typically offered at no cost. The study focused on quantifying the financial burden faced by TB patients seeking care from Myanmar's PPM providers.MethodsThis cross-sectional telephone survey included 695 adults seeking TB treatment [drug-susceptible TB (DS-TB) and retreatment TB] from various private providers in four states and regions with high TB burden in Myanmar. Telephone interviews were conducted in May and June 2022. Both direct and indirect costs incurred from the patient and their household perspective were valued in 2022 and estimated throughout pre- and post-TB treatment episodes. The TB-affected households were defined as experiencing catastrophic health expenditure if their expenditure due to TB exceeded 20% of their capacity to pay, as recommended by the World Health Organization. All cost data were collected in Myanmar Kyats (MMK) and converted to USD (1 USD = 1850 MMK as of July 20, 2022). Logistic regression analysis was done to identify the determinants of catastrophic health expenditure.ResultsThe findings showed patients made a median of 7 times for clinic visits throughout their treatment, with the median total cost for the entire TB treatment being 53.4 US dollars (USD), including direct medical and testing costs (11.9 USD) and direct non-medical patient expenditure (11.6 USD). Pre-treatment costs were higher compared to post-treatment costs (the intensive phase and continuation phase). During the intensive phase, TB care cost was nearly free, but during the continuation phase, it was a median of 2.6 USD. About 34.5% of patients experienced catastrophic health expenditure due to TB treatment, with expenses exceeding 20% of their capacity to pay. Multivariate regression analysis revealed that patients with a history of hospitalization (aOR = 14.84; P < 0.01), seeking care from regions other than Yangon (aOR = 2.6; P < 0.01), and using coping strategies (aOR = 12.53; P < 0.01), were more likely to face catastrophic financial burdens. Higher monthly household income (over 162 USD) was associated with a decreased risk of incurring catastrophic health expenditure (aOR = 0.38; P < 0.01).ConclusionsTB patients and their households in Myanmar faced risk of catastrophic costs, even when treated in the private sector with free diagnostic charges and anti-TB medicine. The study highlighted the need for additional strategies or policies to make TB care affordable and mitigate the financial burden of TB-affected households.Graphical

Leveraging Social Networks to Integrate Depression Treatment into Primary Health and Tuberculosis Care in Brazil.

Tuberculosis (TB) and depression are highly comorbid and linked to higher rates of death and disability. Several evidence-based treatments for depression have been successfully implemented in low- and middle-income countries, but more knowledge is needed on how to bring these innovations to scale within complex 'real world' public health systems. To explore whether the principles of social network analysis could be used to enhance receptivity to integrating depression treatment into primary care for individuals with and without TB in Brazil. We used existing scales to identify settings and providers with high receptivity and connectivity within the primary care network. We trained and supervised existing staff in three primary care sites to deliver a brief evidence-based intervention over one year, coupled with active dissemination activities. Afterwards, we reassessed receptivity among individuals involved, and not involved, in the pilot. Highly significant changes were observed in mental health literacy, attitudes towards evidence-based practices, work self-efficacy, and implementation leadership supporting our hypothesis. Limited social connections between primary care clinics precluded the examination of the hypothesis that targeting settings with high connectivity could capitalize on the information flow between and transcend the decentralized structure of the network, but leveraging the centralized nature of the TB program to integrate mental health services emerged as a promising alternative. The findings of this study strongly suggest that social networks may be leveraged to change individual providers' attitudes, thereby contributing to the enhanced dissemination of evidence-based interventions.

Leveraging digital adherence technologies to enhance public health: insights from TB care in Ukraine

Abstract Background Effective tuberculosis (TB) care is vital for public health, especially in war-affected Ukraine. In response to the complex healthcare delivery landscape, where traditional directly observation treatment methods became impractical, digital adherence technologies (DATs) emerged as a promising solution, offering more autonomy for people, and remote monitoring capabilities for healthcare providers. Intervention The PATH-led USAID-funded Support TB Control Efforts in Ukraine (STBCEU) project implemented smart pill boxes in eleven Ukrainian regions. These devices equipped with built-in reminders helped people adhere to their medication regimen, and signaled healthcare providers when the box was opened. Results Since April 2022, STBCEU has supported 2,022 people with TB who used smart pill boxes during their treatment, including 489 (24%) with drug-resistant TB (DR-TB). A total of 482 people continue utilizing boxes. Of 1,540 people with TB who completed the use of boxes, 1,207 people (78%) successfully completed TB treatment with an average of 84% treatment adherence rate digitally reported by the technology. Conclusions The integration of smart pill boxes in TB management has enhanced people-centered care, ensuring treatment continuity even in challenging circumstances and providing healthcare providers with real-time adherence data. The innovation contributed to TB control efforts and health equity through expanding opportunities for people to choose their treatment model based on their needs, available resources and community support programs. Leveraging digital solutions proved to be essential in strengthening healthcare systems. In the realm of TB management, DATs enhance differentiated care, embodying a harmonious integration of technology automation and provider interventions. Key messages • Integration of smart pill boxes enhanced patient-centered care, providing real-time adherence data and empowering individuals to choose personalized treatment models. • Digital technologies like smart pill boxes transformed TB care, offering tailored support for patients and remote monitoring capabilities for healthcare providers even in challenging circumstances.

Consequences of Disintegrated Care for Dual Tuberculosis and Diabetes in Tanzania: A Case Report on Recurrent Tuberculosis with Severe Haemoptysis in a Patient with Dysregulated Diabetes

Consequences of Disintegrated Care for Dual Tuberculosis and Diabetes in Tanzania: A Case Report on Recurrent Tuberculosis with Severe Haemoptysis in a Patient with Dysregulated Diabetes

The role and value of counsellors in the treatment journeys of people with tuberculosis and their families: Qualitative insights from the South Fly District of Papua New Guinea.

Combined education and counselling can contribute to person-centred care for tuberculosis (TB), improving uptake, adherence, and outcomes of treatment for TB disease and TB infection. Though strongly recommended by the World Health Organization for all people diagnosed with TB, education and counselling is not widely implemented in TB programs around the world. In 2016, a pilot TB education and counselling program, delivered by trained professionals and peers, was initiated to support people on TB treatment in the South Fly District of Papua New Guinea. This article reports on select findings from a qualitative study that examined the socio-cultural dimensions of TB, including treatment support such as education and counselling, in the South Fly District. An assessment on data collected during 128 semi-structured in-depth interviews of the role of counsellors on TB treatment journeys revealed strong participant support for the counsellors and the services they delivered, with particular emphasis on the emotional support provided to address fears and concerns related to TB diagnosis and treatment, and to support treatment adherence; valuable attributes of counsellors; their role as intermediaries between patients and health workers; their provision of biomedical knowledge of TB transmission and disease; and their assistance in addressing stigma and discrimination from family and community. Participants also noted how tackling the socio-structural issues that drive TB transmission in people's homes and communities were beyond the remit of counsellors' work. TB education and counselling should be an essential part of all TB services to provide support and encouragement for people to continue treatment to completion.

Factors Associated with Poor Treatment Outcomes in Newly Diagnosed Tuberculosis Patients in Sub-Sahara Africa: A Systematic Review

Introduction: The burden of Tuberculosis (TB) in Africa continues to rise despite numerous interventions to stop the spread. Addressing factors associated requires a robust model that addresses cross-cutting issues in the continuum of TB care and management. The objective of this systematic review is to determine factors associated with poor treatment outcomes in newly diagnosed TB patients in sub-Saharan Africa. Method: The literature search identified 234 studies that were written in English. All the articles were identified via database search and imported into Mendeley for analysis. A total of 95 duplicates were removed and the abstracts of remaining studies were reviewed. A total of 139 abstracts were screened with misleading and non-open access journal articles removed. A full reading of the remaining 104 potentially relevant studies was done, in order to ascertain compliance with the inclusion/exclusion criteria and 24 studies were found to be eligible and were included in this review. Results: HIV co-infection, type of TB infection and gender were observed as most common factors associated with poor treatment outcomes in newly diagnosed patients. Several studies emphasized the impact of male gender on poor treatment outcomes stating a higher likelihood to developing unfavorable outcomes. Other factors identified included social factors namely employment, location, nutrition, failure to gain weight, failure to present at facility, delay to be treated at the facility and the type of facilities where one was treated. Conclusion: The common factors associated with poor treatment outcomes were HIV co-infection, type of TB infection and gender and these were notably underscored by social factors. Addressing these challenges will significantly improve the health outcomes of TB patients in the region.

Psychological morbidity and quality of life of patients with pulmonary tuberculosis.

Tuberculosis (TB) is associated with psychological distress, poor coping, deterioration in health-related quality of life (HRQL), and stigma. However, these issues have never received sufficient attention as a part of routine care. The healthcare workers and physicians of primary contact are not sensitized to use discrete screening questionnaires to identify and address these issues. A longitudinal study was hence conducted in the Department of Pulmonary Medicine in collaboration with the Department of Psychiatry. 75 microbiologically confirmed 'new' pulmonary TB patients were enrolled. Socio-demographic and clinical details were noted. The patients were then evaluated for psychological distress using the General Health Questionnaire-12-Hindi version (GHQ-12) and Patient Distress Thermometer (PDT); coping strategies using the Coping Strategy Check List-Hindi Version (CSCL); HRQL using the World Health Organization Quality of Life-Brief-Hindi version (WHOQOL-Bref), and stigma using the Explanatory Model Interview Catalogue-affected persons Stigma Scale (EMIC-SS), at the start of treatment. Those having a GHQ-12 score ≥3 were labeled as 'screen positive' for psychological distress and referred to a consultant psychiatrist for detailed psychological assessment. Treatment was given by the psychiatrist if diagnosed with a psychiatric illness. All those without the diagnosis of a psychiatric illness were counseled by a pulmonologist. All patients were called for a follow-up visit and repeat assessments on the 15th day at the end of the intensive phase, using the same instruments employed at baseline. The patients already on treatment by the psychiatrist were again evaluated for their psychiatric illness. 32 (42.7%) patients had psychological distress (GHQ-12≥3) at baseline. 20 of them (26.7%) were diagnosed with a psychiatric illness. However, only 2 (2.7%) patients had psychological distress and psychiatric illness at follow-up (p<0.001). Mean scores of GHQ-12, PDT, CSCL, WHOQOL-Bref-26, and EMIC-SS at baseline were 3.000±1.9590, 2.333±1.2980, 3.480±2.2017, 311.63±30.201 and 5.267±1.8478, respectively. All the scores improved significantly at follow-up (p<0.001). The scores of the various instruments used in the study significantly correlated with each other. Comprehensive screening for psychological distress and assessment of HRQL should be part of routine TB care. The healthcare workers under the program should be sensitized to use the various screening tools on a day-to-day basis to identify patients who require expert psychiatrist care. The majority of the patients with distress, but without a psychiatric illness, can be handled well with dedicated counseling sessions by the healthcare workers themselves. The ancillary staff should be encouraged and trained to meet the demands in resource-constrained settings. A multidisciplinary approach, with close integration of TB programs with mental health services, is urgently required to eliminate TB.

Isoniazid Hybrids As Potential Antitubercular Agents

AbstractThe rapid emergence of various forms of drug‐resistant tuberculosis (TB) has massively impacted people's health globally. According to the WHO, TB care and facilities have been downgraded by 21% since the COVID‐19 pandemic, which has further slowed down the progress toward the “End TB Strategy.” Multiple studies have shown drug‐resistant tuberculosis to be resilient to front‐line antituberculosis drugs, including isoniazid (INH), thus constantly prompting researchers worldwide to probe new potent chemical entities to replace/supplement the current artillery of anti‐TB therapeutics. The molecular hybridization (MH) technique has recently been adopted by many synthetic and medicinal chemists to combine different pharmacophoric units into a single molecular architecture which in most cases has been reported to exhibit a better pharmacological profile as compared to its precursors. The present review provides a concise account of the MH hybridization strategies directed at the structural manipulations of isoniazid to develop new anti‐TB agents and their structure‐activity relationships. Furthermore, their toxicity profiles and docking studies with relevant receptors are also briefly discussed.

Assessing infectiousness and the impact of effective treatment to guide isolation recommendations for people with pulmonary tuberculosis.

Determining the extent and duration of infectiousness of individuals with pulmonary tuberculosis (TB) is critical for various aspects of TB care, including decisions regarding isolation. Studies suggest considerable heterogeneity in infectiousness of people with pulmonary TB. Pre-treatment, measures of bacillary burden including sputum smear microscopy, culture time-to-positivity, and Xpert MTB/RIF cycle threshold (Ct) value, predict the risk of transmission to contacts. Index patients with smear negative disease pose lower infectious risk than those who have smear-positive disease, and household contact infection is more likely with index patients who have lower Xpert Ct values. Newer tools that enable detection of Mycobacterium tuberculosis complex (Mtb complex) from cough aerosol sampling and face mask sampling may be better predictors of contact infection risk. Clinical factors such as cough strength and frequency, and presence of cavitation on chest imaging, may also assist with risk prediction. Post-treatment, smear and culture status are poor predictors of infectiousness. While the exact duration of infectiousness post treatment initiation remains uncertain, data from human-to-guinea pig transmission studies and clinical studies suggest effective treatment results in a rapid decline in infectiousness, irrespective of smear or culture conversion. This is largely supported by early bactericidal activity and transcriptomic studies, and cough aerosol sampling studies, although a subset of patients may have persistent cough aerosol positivity. These findings can enable a more nuanced approach to isolation decision making, while further research studies are awaited.

Public-Private Partnership for Tuberculosis Care and Prevention in Korea.

Public-Private Partnership for Tuberculosis Care and Prevention in Korea.

The influence of comorbidities on treatment outcomes in patients with tuberculosis

To study the association of comorbidities and treatment outcomes in tuberculosis (TB) patients. A retrospective study includes all TB patients aged 18 years and older registered for treatment in Moscow in period 2021 the end of the 3rd quarter of 2022 using data of regional epidemiological TB monitoring system, a total of 3039 patients. The frequency and spectrum of comorbidities, its impact on the risk of adverse treatment outcome (ATO) and mortality using univariate and regression analysis were assessed. Comorbidities were identified in 1528 (50.3%) patients (95% confidence interval - CI 48.5-52.1); HIV infection (18.0%), chronic nonspecific lung disease (9.6%) and cardiovascular disease (8.2%) were predominant. The presence of comorbid pathology increased the odds of uneffective treatment (odds ratio - OR 2.56, 95% CI 2.22-3.03) and death (OR 2.45, 95% СI 1.67-3.59). Independent risk factors for ATO were HIV infection (OR 4.10, 95% CI 3.36-5.10), substance use (OR 2.57, 95% CI 1.70-3.66), chronic nonspecific lung disease (OR 1.39, 95% CI 1.04-1.88), diabetes mellitus (OR 1.69, 95% CI 1.15-2.48), liver pathology (OR 2.10, 95% CI 1.46-3.03), mental illness (OR 2.01, 95% CI 1.32-3.06). The death rate was 13.4%; the most significant predictors of mortality were HIV infection (OR 3.89, 95% CI 2.42-6.22) and liver disease (OR 1.90, 95% CI 1.27-2.82). A comorbidome model was constructed to assess the importance of different comorbidities for patient prognosis. The presence of comorbidity (predominantly HIV infection and liver disease) is a significant risk factor for ATO and mortality in TB patients, which should be taken into account when organizing and providing TB care to comorbid patients.

Nutritional Supplementation in Tuberculosis Treatment: A Mixed Methods Study of Clinical Outcomes and Patient Perceptions in Jamnagar, India.

Tuberculosis (TB) remains a significant global health challenge, with malnutrition being a key risk factor for poor outcomes. This study aimed to evaluate the impact of nutritional supplementation on treatment outcomes in drug-sensitive pulmonary tuberculosis (DS-PTB) patients and explore patient perspectives on nutrition during TB treatment. We conducted a mixed methods study in the Jamnagar district of Gujarat, India. The quantitative component was a retrospective cohort study comparing 645 DS-PTB patients who received nutritional supplements with 645 patients who did not. The primary outcomes were cure rates, mortality, and weight gain. Qualitative data were collected through in-depth interviews of 240 patients to explore their experiences and perceptions regarding nutrition during TB treatment. Patients receiving nutritional supplements had significantly higher cure rates (482/645, n=74.7% vs 328/645, n=50.9%, OR: 2.86, 95% CI: 2.26-3.61, p<0.001) and lower mortality (7/645, n=1.1% vs 37/645, n=5.7%, OR: 0.18, 95% CI: 0.08-0.41, p<0.001) compared to the non-supplemented group. The group that received nutritional supplementation showed greater weight gain over six months (6.5 kg vs 3.1 kg, p<0.001). Qualitative findings revealed that patients who received nutritional supplementation reported improved appetite, increased energy, and faster symptom resolution while control group participants faced financial constraints and reduced appetite as barriers to adequate nutrition. Nutritional supplementation significantly improved treatment outcomes in DS-PTB patients, including higher cure rates, reduced mortality, and enhanced weight gain. Patient perspectives highlighted the multifaceted impact of nutritional support. These findings suggest that integrating nutritional supplementation into standard TB care could substantially improve patient outcomes and experiences.

A pilot program to improve TB care with primary and specialty care coordination in TB public health clinic

&lt;sec&gt;&lt;title&gt;BACKGROUND&lt;/title&gt;The Wetmore Tuberculosis (TB) Clinic in New Orleans serves patients who often lack primary care (PC) or specialty care (SC), which is complicated by comorbidities. An initiative to provide on-site PC and coordinate care aims to enhance TB patient management.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;METHODS&lt;/title&gt;Data collection involved categorizing patients based on their PC status: Group I (regular PC), Group II (intermittent PC), and Group III (no PC), with on-site Nurse Practitioner-based Bridge Care (NPBC) provided as needed.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;RESULTS&lt;/title&gt;Over 12 months, 209 out of 354 patients required NPBC and PC/SC coordination, with a 20% shift from Group III to Group I, reducing the need for NPBC.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;CONCLUSION&lt;/title&gt;The program improved TB care at Wetmore TB Clinic, offering a potential model for other TB clinics to enhance patient adherence and TB and post-TB treatment follow-up.&lt;/sec&gt;

An approach to integrated management of diabetes in tuberculosis patients: Availability and readiness of the health facilities of Bangladesh.

Comorbidity of diabetes mellitus and tuberculosis (TB) is a major public health concern in low- and middle-income countries including Bangladesh. An integrated approach is required for adequate management of diabetes mellitus and TB. The objective of the present study was to investigate the availability and readiness of the TB care centers of Bangladesh toward diabetic patients' management. The present study was conducted based on existing data obtained from the Bangladesh Health Facility Survey (BHFS) 2017. Data collected from a total of 303 facilities providing TB services were retrieved. The outcome variables of the present study were availability and readiness of the TB health facilities for providing diabetes mellitus service. Readiness was measured for four domains: staff and guidelines, equipment, diagnostic facility and basic medicine. The independent variables were: facility level, management authority and location of the facility. Binary and multiple logistic regression models were constructed for both the outcome variables (availability and readiness) to find out their predictors. Services for diabetes mellitus were available in 68% of the TB facilities while high readiness was present in 36% of the facilities. For domain-specific readiness index, readiness for the domains of staff and guidelines, equipment, diagnostic facility and basic medicine was reported in 46%, 96%, 38% and 25% facilities respectively. In the logistic regression model, availability of diabetes mellitus services was better in primary level (aOR 2.62, 95% CI 1.78-4.77) and secondary level (aOR 3.26, 95% CI 1.82-9.05) facilities than community facilities. Similarly, readiness of diabetes mellitus care was also better in these facilities (aOR 2.55, 95% CI 1.05-4.71 for primary and aOR 2.75, 95% CI 1.80-4.32 for secondary facilities). Besides, private TB facilities had better availability (aOR 2.84, 95% CI 1.75-5.89) and readiness (aOR 2.52, 95% CI 1.32-4.29) for diabetes mellitus care. Availability and readiness for providing diabetes mellitus services in TB care providing facilities in Bangladesh is inadequate.

Drug-resistant tuberculosis care and treatment outcomes over the last 15 years in Ethiopia: Results from a mixed-method review of trends.

Drug resistant tuberculosis (DR-TB) remains a global challenge with about a third of the cases are not detected. With the recent advances in the diagnosis and treatment follow-up of DR-TB, there have been improvements with treatment success rates. However, there is limited evidence on the successful models of care that have consistently registered good outcomes. Our aim was to assess Ethiopia's experience in scaling up an ambulatory, decentralized model of care while managing multiple regimen transition processes and external shocks. This was a cross-sectional, mixed-method study. For the quantitative data, we reviewed routine surveillance data for the period 2009-2022 and collected additional data from publicly available reports. We then analyzed the data descriptively. Qualitative data were collected from program reports, quarterly presentations, minutes of technical working group meetings, and clinical review committee reports and analyzed thematically. The number of DR-TB treatment initiating centers increased from 1 to 67, and enrollment increased from 88 in 2010 to 741 in 2019, but declined to 518 in 2022. A treatment success rate (TSR) of over 70% was sustained. The decentralized and ambulatory service delivery remained the core service delivery model. The country successfully navigated multiple regimen transitions, including the recently introduced six-month short oral regimen. Several challenges remain, including the lack of strong and sustainable specimen transportation system, lack of established systems for timely tracing and linking of missed DR-TB cases, and data quality issues. Ethiopia scaled up a decentralized ambulatory model of care, kept up to date with recent developments in treatment regimens, and maintained a high TSR, despite the influence of multiple external challenges. The recent decline in case notification requires a deeper look into the underlying reasons. The feasibility of fully integrating DR-TB treatment and follow up at community level should be explored further.

Developing an AI-Assisted Platform to Support Tuberculosis Care Delivery.

Artificial Intelligence (AI) has the potential to "bridge the gap" between healthcare provider and patient needs in low-resource settings to deliver timely, personalized, and empathetic care to individuals with active tuberculosis.

Tuberculosis treatment loss to follow-up in children exposed at home: A prospective cohort study.

Loss to follow-up (LTFU) from tuberculosis (TB) treatment and care is a significant public health problem. It is important to understand what drives LTFU in children - a population whose treatment and management depend on an adult caregiver - to better provide support services to families affected by TB. We conducted a prospective cohort study of household contacts in Lima, Peru (2009-12). Using multilevel logistic regression analysis, we explored individual-level characteristics of children and their adult household members with TB disease to identify risk factors for LTFU among children initiated on treatment for TB. A total of 154 child (0-14 years) household contacts were diagnosed with TB and initiated on treatment. While most (n = 133, 86.4%) had a successful outcome, 20 (13.0%) children were LTFU. Six (30.0%) children were LTFU within three months, nine (45.0%) between five to seven months, and three (15.0%) after seven months of treatment being initiated. In univariable analysis, children with index patients above 25 years of age had decreased odds of being LTFU (odds ratio = 0.26; 95% confidence interval = 0.08-0.84) compared to children with index patients 25 years or younger. In this cohort, more than 10% of children sick with TB who were exposed to the disease at home were LTFU. An integrated, family-centred TB prevention and management approach may reduce barriers to a child completing their course of TB treatment.

“As a patient I do not belong to the clinic, I belong to the community”: co-developing multi-level, person-centred tuberculosis stigma interventions in Cape Town, South Africa

BackgroundAnticipated, internal, and enacted stigma are major barriers to tuberculosis (TB) care engagement and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.MethodsUsing a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n = 87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed, and then further interpreted using the socio-ecological model and behaviour change wheel framework.ResultsIntervention components across socio-ecological levels shared common functions linked to effective behaviour change, namely education, training, enablement, persuasion, modelling, and environmental restructuring. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal and anticipated stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended to decrease enacted stigma. Participants discussed how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.ConclusionsDecreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-led multi-level intervention components should be prioritised by TB programs, including integrated TB/HIV care services.