Health care seeking patterns of rifampicin-resistant tuberculosis patients in Harare, Zimbabwe: A prospective cohort study.
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ABSTRACT: Background
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.Method
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.Results
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.Conclusions
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.
SUBMITTER: Tadokera R
PROVIDER: S-EPMC8284678 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:Zimbabwe is one of the thirty countries globally with a high burden of multidrug-resistant tuberculosis (TB) or rifampicin-resistant TB (MDR/RR-TB). Since 2010, patients diagnosed with MDR/RR-TB are being treated with 20-24 months of standardized second-line drugs (SLDs). The profile, management and factors associated with unfavourable treatment outcomes of MDR/RR TB have not been systematically evaluated in Zimbabwe. OBJECTIVE:To assess treatment outcomes and factors associated with unfavourable outcomes among MDR/RR-TB patients registered and treated under the National Tuberculosis Programme in all the district hospitals and urban healthcare facilities in Zimbabwe between January 2010 and December 2015. METHODS:A cohort study using routinely collected programme data. The 'death', 'loss to follow-up' (LTFU), 'failure' and 'not evaluated' were considered as "unfavourable outcome". A generalized linear model with a log-link and binomial distribution or a Poisson distribution with robust error variances were used to assess factors associated with "unfavourable outcome". The unadjusted and adjusted relative risks were calculated as a measure of association. A ?value< 0.05 was considered statistically significant. RESULTS:Of the 473 patients in the study, the median age was 34 years [interquartile range, 29-42] and 230 (49%) were males. There were 352 (74%) patients co-infected with HIV, of whom 321 (91%) were on antiretroviral therapy (ART). Severe adverse events (SAEs) were recorded in 118 (25%) patients; mostly hearing impairments (70%) and psychosis (11%). Overall, 184 (39%) patients had 'unfavourable' treatment outcomes [125 (26%) were deaths, 39 (8%) were lost to follow-up, 4 (<1%) were failures and 16 (3%) not evaluated]. Being co-infected with HIV but not on ART [adjusted relative risk (aRR) = 2.60; 95% CI: 1.33-5.09] was independently associated with unfavourable treatment outcomes. CONCLUSION:The high unfavourable treatment outcomes among MDR/RR-TB patients on standardized SLDs were coupled with a high occurrence of SAEs in this predominantly HIV co-infected cohort. Switching to individualized all oral shorter treatment regimens should be considered to limit SAEs and improve treatment outcomes. Improving the ART uptake and timeliness of ART initiation can reduce unfavourable outcomes.
| S-EPMC7192497 | biostudies-literature
Project description:BackgroundData on long-term outcomes of patients receiving antiretroviral therapy (ART) in sub-Saharan Africa are few. We describe outcomes of patients commenced on ART at Newlands Clinic between 2004 and 2006 after ≥10 years of comprehensive care including, psychosocial, adherence and food support.MethodsIn this retrospective cohort study, patient data from an electronic medical record collected during routine care were analysed. We describe baseline characteristics, virological and clinical outcomes, attrition rates, and treatment adverse effects until November 2016. We defined virological suppression as viral load <50 copies/ml and virological failure as >1000 copies/ml after ≥6 months of ART.ResultsWe analysed data for 605 patients (67% female) who commenced ART, and were followed-up for 5819 person-years (median: 10.7 years, IQR: 10.1-11.4). Median age at ART initiation was 34 years (IQR: 17-42). Pre-ART, 129 (21.3%) patients had history of pulmonary tuberculosis (PTB). In care, 66 (11%) developed PTB, and 24 (4%) developed extrapulmonary tuberculosis. 385 (63.6%) patients experienced ≥1 adverse event, the most frequent being stavudine-induced peripheral neuropathy (n = 252, 41.7%). At database closure on 14 November 2016, 474 (78.3%) patients were still in care, 428 (90.3%) being virologically suppressed, and 21 (4.4%) failing. While 483 (79.8%) remained on first line, 122 (20.2%) were switched to second line ART. Fifty-nine patients (9.8%) were transferred to other ART facilities, 45 (7.4%) were lost to follow-up, 25 (4.1%) died, and two stopped ART.ConclusionComprehensive HIV care can result in low mortality, high retention in care and virologic suppression rates in resource limited settings.
| S-EPMC5655537 | biostudies-literature
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| S-EPMC9403354 | biostudies-literature
Project description:BackgroundDetermining factors affecting the transmission of rifampicin (RR) and multidrug-resistant (MDR) Mycobacterium tuberculosis complex strains under standardized tuberculosis (TB) treatment is key to control TB and prevent the evolution of drug resistance.MethodsWe combined bacterial whole genome sequencing (WGS) and epidemiological investigations for 37% (n = 195) of all RR/MDR-TB patients in Cameroon (2012-2015) to identify factors associated with recent transmission.ResultsPatients infected with a strain resistant to high-dose isoniazid, and ethambutol had 7.4 (95% CI 2.6-21.4), and 2.4 (95% CI 1.2-4.8) times increased odds of being in a WGS-cluster, a surrogate for recent transmission. Furthermore, age between 30 and 50 was positively correlated with recent transmission (adjusted OR 3.8, 95% CI 1.3-11.4). We found high drug-resistance proportions against three drugs used in the short standardized MDR-TB regimen in Cameroon, i.e. high-dose isoniazid (77.4%), ethambutol (56.9%), and pyrazinamide (43.1%). Virtually all strains were susceptible to fluoroquinolones, kanamycin, and clofazimine, and treatment outcomes were mostly favourable (87.5%).ConclusionPre-existing resistance to high-dose isoniazid, and ethambutol is associated with recent transmission of RR/MDR strains in our study. A possible contributing factor for this observation is the absence of universal drug susceptibility testing in Cameroon, likely resulting in prolonged exposure of new RR/MDR-TB patients to sub-optimal or failing first-line drug regimens.
| S-EPMC8406724 | biostudies-literature
Project description:RationaleCentral dogma suggests that rifampicin resistance in Mycobacterium tuberculosis develops solely through rpoB gene mutations.ObjectiveTo determine whether rifampicin induces efflux pumps activation in rifampicin resistant M. tuberculosis strains thereby defining rifampicin resistance levels and reducing ofloxacin susceptibility.MethodsRifampicin and/or ofloxacin minimum inhibitory concentrations (MICs) were determined in rifampicin resistant strains by culture in BACTEC 12B medium. Verapamil and reserpine were included to determine their effect on rifampicin and ofloxacin susceptibility. RT-qPCR was applied to assess expression of efflux pump/transporter genes after rifampicin exposure. To determine whether verapamil could restore susceptibility to first-line drugs, BALB/c mice were infected with a MDR-TB strain and treated with first-line drugs with/without verapamil.Measurements and main findingsRifampicin MICs varied independently of rpoB mutation and genetic background. Addition reserpine and verapamil significantly restored rifampicin susceptibility (p = 0.0000). RT-qPCR demonstrated that rifampicin induced differential expression of efflux/transporter genes in MDR-TB isolates. Incubation of rifampicin mono-resistant strains in rifampicin (2 μg/ml) for 7 days induced ofloxacin resistance (MIC > 2 μg/ml) in strains with an rpoB531 mutation. Ofloxacin susceptibility was restored by exposure to efflux pump inhibitors. Studies in BALB/c mice showed that verapamil in combination with first-line drugs significantly reduced pulmonary CFUs after 1 and 2 months treatment (p < 0.05).ConclusionExposure of rifampicin resistant M. tuberculosis strains to rifampicin can potentially compromise the efficacy of the second-line treatment regimens containing ofloxacin, thereby emphasising the need for rapid diagnostics to guide treatment. Efflux pump inhibitors have the potential to improve the efficacy of anti-tuberculosis drug treatment.
| S-EPMC3698754 | biostudies-literature
Project description:Country-specific interventions targeting high-risk groups are necessary for a global reduction in Tuberculosis (TB)/HIV burden. We analyzed the data of 13,802 TB cases diagnosed in Harare, Zimbabwe, during 2013-2017. Pearson's chi-square tests and multivariate logistic regression models were used to identify patient characteristics significantly associated with TB/HIV coinfection. Of the 13,802 TB cases analyzed, 9,725 (70.5%) were HIV positive. A significantly higher odds of having TB/HIV coinfection diagnosis was found among females, patients aged 25-64 years, previously treated cases, and acid-fast bacillus sputum smear-negative cases. Compared with nondisseminated pulmonary TB, miliary TB (adjusted odds ratio [aOR]: 1.469, 95% CI: 1.071, 2.015) and TB meningitis (aOR: 1.715, 95% CI: 1.074, 2.736) both had a significantly higher odds for TB/HIV coinfection, whereas pleural TB (aOR 0.420, 95% CI: 0.354, 0.497) and all other extrapulmonary TB (EPTB) (aOR: 0.606, 95% CI: 0.516 0.712) were significantly less likely to have TB/HIV coinfection. The risk for TB/HIV coinfection varied significantly by patients' sociodemographic and clinical characteristics in Harare. Our finding that different forms of EPTB have different relationships with HIV coinfection has extended the knowledge base about clinical markers for TB/HIV coinfection which can lead to a greater public health impact on eliminating TB/HIV infection.
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Project description:BACKGROUND:Cervical cancer is a major cause of morbidity and mortality among women yet access to treatment and care remains a huge challenge in Zimbabwe. The objective of this study was to investigate health system constraints affecting engagement into treatment and care by women with cervical cancer in Harare, Zimbabwe. METHODS:A sequential explanatory mixed methods design was used for this study. Phase 1 comprised of two surveys namely: patient and health worker surveys with sample sizes of 134 and 78 participants respectively. Validated structured questionnaires programmed in Android tablet with SurveytoGo software were used for data collection during the surveys. Univariate analyses were conducted using STATA® version 14 to generate descriptive statistics. In phase 2, 16 in-depth interviews, 20 key informant interviews and 6 focus groups were conducted to explain survey results. Participants were purposively selected and sample sizes were informed by saturation principle. Participants in phase 1 and 2 were different. English transcripts were manually coded line by line in Dedoose software using the thematic codes that had been established from the survey data. The final codes were used to support and explain the survey data at the interpretation stages. RESULTS:Health system constraints identified in surveys were: limited or lack of training for health workers, weakness of surveillance system for cervical cancer, limited access to treatment and care, inadequate health workers, reliance of patients on out-of-pocket funding for treatment services, lack of back-up for major equipment. Qualitative inquiry revealed the following barriers to treatment and care: high costs of treatment and care, lack of knowledge about cervical cancer and bad attitudes of health workers, few screening and treating centres located mostly in urban areas, lack of clear referral system resulting in bureaucratic processes, and limited screening and treating capacities in health facilities due to lack of resources. CONCLUSION:The results of this study show that health system and its organization present barriers to access of cervical cancer treatment and care among women. Strong political will, mobilization of resources both domestically and from partners in addition to sound policies are imperative to address key health system challenges.
| S-EPMC6852958 | biostudies-literature
Project description:BackgroundThere are few data on the on the care experiences of pregnant women with rifampicin-resistant TB.ObjectiveTo describe the treatment journeys of pregnant women with RR-TB-including how their care experiences shape their identities-and identify areas in which tailored interventions are needed.MethodsIn this qualitative study in-depth interviews were conducted among a convenience sample from a population of pregnant women receiving treatment for RR-TB. This paper follows COREQ guidelines. A thematic network analysis using an inductive approach was performed to analyze the interview transcripts and notes. The analysis was iterative and a coding system developed which focused on the care experiences of the women and how these experiences affected their perceptions of themselves, their children, and the health care system in which treatment was received.ResultsSeventeen women were interviewed. The women described multiple challenges in their treatment journeys which required them to demonstrate sustained resilience (i.e. to "be brave"). Care experiences required them to negotiate seemingly contradictory identities as both new mothers-"givers of life"-and RR-TB patients facing a complicated and potentially deadly disease. In terms of their "pregnancy identity" and "RR-TB patient identity" that emerged as part of their care experiences, four key themes were identified that appeared to have elements that were contradictory to one another (contradictory areas). These included: 1) the experience of physical symptoms or changes; 2) the experience of the "mothering" and "patient" roles; 3) the experience of the care they received for their pregnancy and their RR-TB; and 4) the experience of community engagement. There were also three areas that overlapped with both roles and during which identity was negotiated/reinforced and they included: 1) faith; 2) socioeconomic issues; and 3) long-term concerns over the child's health. At times, the health care system exacerbated these challenges as the women were not given the support they needed by health care providers who were ill-informed or angry and treated the women in a discriminatory fashion. Left to negotiate this confusing time period, the women turned to faith, their own mothers, and the fathers of their unborn children.ConclusionThe care experiences of the women who participated in this study highlight several gaps in the current health care system that must be better addressed in both TB and perinatal services in order to improve the therapeutic journeys for pregnant women with RR-TB and their children. Suggestions for optimizing care include the provision of integrated services, including specialized counseling as well as training for health care providers; engagement of peer support networks; provision of socioeconomic support; long-term medical care/follow-up for children born to women who were treated for RR-TB; and inclusion of faith-based services in the provision of care.
| S-EPMC7751874 | biostudies-literature
Project description:IntroductionGlobally people with tuberculosis (TB) continue to be missed each year. They are either not diagnosed or not reported which indicates possible leakages in the TB care cascade. Zimbabwe is not spared with over 12000 missed cases in 2020. A preliminary review of TB treatment outcomes indicated patient leakages throughout the presumptive cascade and undesirable treatment outcomes in selected cities. Chegutu District had pre-diagnosis and pretreatment losses to follow-up while Mutare City among others had 22.0% of outcomes not evaluated in the second quarter of 2021, and death rates as high as 14% were recorded in Gweru District. The problem persists despite training on data analysis and use. The TB cohorts were analysed to determine the performance of the care cascade and the spatial distribution of treatment outcomes in Zimbabwe.MethodsUsing data from district health information software version 2.3 (DHIS2.3), a secondary data analysis of 2020 drug-sensitive (DS) TB treatment cohorts was conducted. We calculated the percentage of pre-diagnosis, and pre-treatment loss to follow-up (LTFU). For TB treatment outcomes, 'cured' and 'treatment completed' were categorized as treatment success, while 'death', 'loss to follow-up (LTFU), and 'not evaluated' were categorized as undesirable outcomes. Univariate analysis of the data was conducted where frequencies were calculated, and data was presented in graphs for the cascade, treatment success, and undesirable outcomes while tables were created for the description of study participants and data quality. QGIS was used to generate maps showing undesirable treatment outcomes.ResultsAn analysis of national data found 107583 people were presumed to have TB based on symptomatic screening and or x-ray and 21.4% were LTFU before the specimen was investigated. Of the 84534 that got tested, 10.0% did not receive their results. The treatment initiation rate was 99.1%. Analysis of treatment outcomes done at the provincial level showed that Matabeleland South Province had the lowest treatment success rate of 77.3% and high death rates were recorded in Matabeleland South (30.0%), Masvingo (27.3%), and Matabeleland North (26.1%) provinces. Overall, there were high percentages of not-evaluated treatment outcomes.ConclusionPre-diagnosis LTFU was high, and high death and loss to follow-up rates were prevalent in provinces with artisanal and small-scale mining (ASM) activities. Unevaluated treatment outcomes were also prevalent and data quality remains a challenge within the national TB control program. We recommended strengthening patient follow-up at all levels within the TB care cascade, strengthening capacity-building for data analysis and use, further analysis to determine factors associated with undesirable outcomes and a study on why LTFU remains high.
| S-EPMC10631662 | biostudies-literature
Project description:IntroductionThe scale-up of antiretroviral therapy (ART) across sub-Saharan Africa (SSA) has reduced mortality so that increasing numbers of children with HIV (CWH) are surviving to adolescence. However, they experience a range of morbidities due to chronic HIV infection and its treatment. Impaired linear growth (stunting) is a common manifestation, affecting up to 50% of children. However, the effect of HIV on bone and muscle development during adolescent growth is not well characterised. Given the close link between pubertal timing and musculoskeletal development, any impairments in adolescence are likely to impact on future adult musculoskeletal health. We hypothesise that bone and muscle mass accrual in CWH is reduced, putting them at risk of reduced bone mineral density (BMD) and muscle function and increasing fracture risk. This study aims to determine the impact of HIV on BMD and muscle function in peripubertal children on ART in Zimbabwe.Methods and analysisChildren with (n=300) and without HIV (n=300), aged 8-16 years, established on ART, will be recruited into a frequency-matched prospective cohort study and compared. Musculoskeletal assessments including dual-energy X-ray absorptiometry, peripheral quantitative computed tomography, grip strength and standing long jump will be conducted at baseline and after 1?year. Linear regression will be used to estimate mean size-adjusted bone density and Z-scores by HIV status (ie, total-body less-head bone mineral content for lean mass adjusted for height and lumbar spine bone mineral apparent density. The prevalence of low size-adjusted BMD (ie, Z-scores <-2) will also be determined.Ethics and disseminationEthical approval for this study has been granted by the Medical Research Council of Zimbabwe and the London School of Hygiene and Tropical Medicine Ethics Committee. Baseline and longitudinal analyses will be published in peer-reviewed journals and disseminated to research communities.
| S-EPMC7045196 | biostudies-literature