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Naidoo K, Perumal R, Cox H, Mathema B, Loveday M, Ismail N, Omar SV, Georghiou SB, Daftary A, O'Donnell M, Ndjeka N. The epidemiology, transmission, diagnosis, and management of drug-resistant tuberculosis-lessons from the South African experience. THE LANCET. INFECTIOUS DISEASES 2024; 24:e559-e575. [PMID: 38527475 DOI: 10.1016/s1473-3099(24)00144-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/29/2024] [Accepted: 02/20/2024] [Indexed: 03/27/2024]
Abstract
Drug-resistant tuberculosis (DR-TB) threatens to derail tuberculosis control efforts, particularly in Africa where the disease remains out of control. The dogma that DR-TB epidemics are fueled by unchecked rates of acquired resistance in inadequately treated or non-adherent individuals is no longer valid in most high DR-TB burden settings, where community transmission is now widespread. A large burden of DR-TB in Africa remains undiagnosed due to inadequate access to diagnostic tools that simultaneously detect tuberculosis and screen for resistance. Furthermore, acquisition of drug resistance to new and repurposed drugs, for which diagnostic solutions are not yet available, presents a major challenge for the implementation of novel, all-oral, shortened (6-9 months) treatment. Structural challenges including poverty, stigma, and social distress disrupt engagement in care, promote poor treatment outcomes, and reduce the quality of life for people with DR-TB. We reflect on the lessons learnt from the South African experience in implementing state-of-the-art advances in diagnostic solutions, deploying recent innovations in pharmacotherapeutic approaches for rapid cure, understanding local transmission dynamics and implementing interventions to curtail DR-TB transmission, and in mitigating the catastrophic socioeconomic costs of DR-TB. We also highlight globally relevant and locally responsive research priorities for achieving DR-TB control in South Africa.
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Affiliation(s)
- Kogieleum Naidoo
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Rubeshan Perumal
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Helen Cox
- Institute of Infectious Diseases and Molecular Medicine, Wellcome Centre for Infectious Disease Research and Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Barun Mathema
- Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Marian Loveday
- South African Medical Research Council, Durban, South Africa
| | - Nazir Ismail
- School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Shaheed Vally Omar
- Centre for Tuberculosis, National & WHO Supranational TB Reference Laboratory, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
| | | | - Amrita Daftary
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; School of Global Health and Dahdaleh Institute of Global Health Research, York University, Toronto, ON, Canada
| | - Max O'Donnell
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY, USA; Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY, USA
| | - Norbert Ndjeka
- TB Control and Management, Republic of South Africa National Department of Health, Pretoria, South Africa
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Zary M, Mohamed MS, Kafie C, Chilala CI, Bahukudumbi S, Foster N, Gore G, Fielding KL, Subbaraman R, Schwartzman K. The performance of digital technologies for measuring tuberculosis medication adherence: a systematic review. BMJ Glob Health 2024; 9:e015633. [PMID: 39013639 PMCID: PMC11288144 DOI: 10.1136/bmjgh-2024-015633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024] Open
Abstract
INTRODUCTION Digital adherence technologies (DATs), such as phone-based technologies and digital pillboxes, can provide more person-centric approaches to support tuberculosis (TB) treatment. However, there are varying estimates of their performance for measuring medication adherence. METHODS We conducted a systematic review (PROSPERO-CRD42022313526), which identified relevant published literature and preprints from January 2000 to April 2023 in five databases. Studies reporting quantitative data on the performance of DATs for measuring TB medication adherence against a reference standard, with at least 20 participants, were included. Study characteristics and performance outcomes (eg, sensitivity, specificity and predictive values) were extracted. Sensitivity was the proportion correctly classified as adherent by the DAT, among persons deemed adherent by a reference standard. Specificity was the proportion correctly classified as non-adherent by the DAT, among those deemed non-adherent by a reference standard. RESULTS Of 5692 studies identified by our systematic search, 13 met inclusion criteria. These studies investigated medication sleeves with phone calls (branded as '99DOTS'; N=4), digital pillboxes N=5), ingestible sensors (N=2), artificial intelligence-based video-observed therapy (N=1) and multifunctional mobile applications (N=1). All but one involved persons with TB disease. For medication sleeves with phone calls, compared with urine testing, reported sensitivity and specificity were 70%-94% and 0%-61%, respectively. For digital pillboxes, compared with pill counts, reported sensitivity and specificity were 25%-99% and 69%-100%, respectively. For ingestible sensors, the sensitivity of dose detection was ≥95% compared with direct observation. Participant selection was the most frequent potential source of bias. CONCLUSION The limited number of studies available suggests suboptimal and variable performance of DATs for dose monitoring, with significant evidence gaps, notably in real-world programmatic settings. Future research should aim to improve understanding of the relationships of specific technologies, settings and user engagement with DAT performance and should measure and report performance in a more standardised manner.
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Affiliation(s)
- Miranda Zary
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mona Salaheldin Mohamed
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Cedric Kafie
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Shruti Bahukudumbi
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nicola Foster
- TB Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Genevieve Gore
- McGill Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Quebec, Canada
| | | | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Kevin Schwartzman
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Reis K, Wolf A, Perumal R, Seepamore B, Guzman K, Ross J, Cheung K, Amico KR, Brust JC, Padayatchi N, Friedland G, Naidoo K, Daftary A, Zelnick J, O’Donnell M. Differentiated service delivery framework for people with multidrug-resistant tuberculosis and HIV co-infection. J Acquir Immune Defic Syndr 2024; 96:00126334-990000000-00374. [PMID: 38323838 PMCID: PMC11300702 DOI: 10.1097/qai.0000000000003394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
INTRODUCTION For people living with HIV/AIDS, care is commonly delivered through Differentiated Service Delivery (DSD). Although people with multidrug-resistant tuberculosis (MDR-TB) and HIV/AIDS experience severe treatment associated challenges, there is no DSD model to support their treatment. In this study, we defined patterns of medication adherence and characterized longitudinal barriers to inform development of an MDR-TB/HIV DSD framework. METHODS Adults with MDR-TB and HIV initiating bedaquiline (BDQ) and receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa, were enrolled and followed through the end of MDR-TB treatment. Electronic dose monitoring devices (EDM) measured BDQ and ART adherence. Longitudinal focus groups were conducted and transcripts analyzed thematically to describe discrete treatment stage-specific and cross-cutting treatment challenges. RESULTS 283 participants were enrolled and followed through treatment completion (median 17.8 months [IQR 16.5-20.2]). Thirteen focus groups were conducted. Most participants (82.7%, 234/283) maintained high adherence (mean BDQ adherence 95.3%; mean ART adherence 85.5%), but an adherence-challenged subpopulation with <85% cumulative adherence (17.3%, 49/283) had significant declines in mean weekly BDQ adherence from 94.9% to 39.9% (p<0.0001) and mean weekly ART adherence from 83.9% to 26.6% (p<0.0001) over 6 months. Psychosocial, behavioral, and structural obstacles identified in qualitative data were associated with adherence deficits in discrete treatment stages, and identified potential stage specific interventions. CONCLUSION A DSD framework for MDR-TB/HIV should intensify support for adherence-challenged subpopulations, provide multi-modal support for adherence across the treatment course and account for psychosocial, behavioral, and structural challenges linked to discrete treatment stages.
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Affiliation(s)
- Karl Reis
- Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
| | - Rubeshan Perumal
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Boitumelo Seepamore
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Kevin Guzman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
| | - Jesse Ross
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
| | - Ken Cheung
- Department of Biostatistics, Columbia University Irving Medical Center, New York City, NY
| | - K. Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI
| | - James C.M. Brust
- Divisions of General Internal Medicine and Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Nesri Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Gerald Friedland
- Department of Medicine (Infections Diseases), Yale University School of Medicine, New Haven, CT
| | - Kogieleum Naidoo
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Amrita Daftary
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Canada
| | - Jennifer Zelnick
- Graduate School of Social Work, Touro University, New York City, NY
| | - Max O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY
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Faisal S, Samoth D, Aslam Y, Patel H, Park S, Baby B, Patel T. Key Features of Smart Medication Adherence Products: Updated Scoping Review. JMIR Aging 2023; 6:e50990. [PMID: 38113067 PMCID: PMC10762620 DOI: 10.2196/50990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/25/2023] [Accepted: 11/19/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Older adults often face challenges in self-managing their medication owing to physical and cognitive limitations, complex medication regimens, and packaging of medications. Emerging smart medication dispensing and adherence products (SMAPs) offer the options of automated dispensing, tracking medication intake in real time, and reminders and notifications. A 2021 review identified 51 SMAPs owing to the rapid influx of digital technology; an update to this review is required. OBJECTIVE This review aims to identify new products and summarize and compare the key features of SMAPs. METHODS Gray and published literature and videos were searched using Google, YouTube, PubMed, Embase, and Scopus. The first 10 pages of Google and the first 100 results of YouTube were screened using 4 and 5 keyword searches, respectively. SMAPs were included if they were able to store and allowed for the dispensation of medications, tracked real-time medication intake data, and could automatically analyze data. Products were excluded if they were stand-alone software applications, not marketed in English, not for in-home use, or only used in clinical trials. In total, 5 researchers independently screened and extracted the data. RESULTS This review identified 114 SMAPs, including 80 (70.2%) marketed and 34 (29.8%) prototypes, grouped into 15 types. Among the marketed products, 68% (54/80) were available for consumer purchase. Of these products, 26% (14/54) were available worldwide and 78% (42/54) were available in North America. There was variability in the hardware, software, data collection and management features, and cost of the products. Examples of hardware features include battery life, medication storage capacity, availability of types and number of alarms, locking features, and additional technology required for use of the product, whereas software features included reminder and notification capabilities and availability of manufacturer support. Data capture methods included the availability of sensors to record the use of the product and data-syncing capabilities with cloud storage with short-range communications. Data were accessible to users via mobile apps or web-based portals. Some SMAPs provided data security assurance with secure log-ins (use of personal identification numbers or facial recognition), whereas other SMAPs provided data through registered email addresses. Although some SMAPs were available at set prices or free of cost to end users, the cost of other products varied based on availability, shipping fees, and subscription fees. CONCLUSIONS An expanding market for SMAPs with features specific to at-home patient use is emerging. Health care professionals can use these features to select and suggest products that meet their patients' unique requirements.
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Affiliation(s)
- Sadaf Faisal
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Devine Samoth
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Yusra Aslam
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Hawa Patel
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - SooMin Park
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Bincy Baby
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Tejal Patel
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
- Schlegel - University of Waterloo Research Institute of Aging, Waterloo, ON, Canada
- Centre for Family Medicine Family Health Team, Kitchener, ON, Canada
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Ross J, Perumal R, Wolf A, Zulu M, Guzman K, Seepamore B, Reis K, Nyilana H, Hlathi S, Narasimmulu R, Cheung YKK, Amico KR, Friedland G, Daftary A, Zelnick JR, Naidoo K, O'Donnell MR. Adaptive evaluation of mHealth and conventional adherence support interventions to optimize outcomes with new treatment regimens for drug-resistant tuberculosis and HIV in South Africa (ADAP-TIV): study protocol for an adaptive randomized controlled trial. Trials 2023; 24:776. [PMID: 38037105 PMCID: PMC10691086 DOI: 10.1186/s13063-023-07520-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/17/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Highly effective, short-course, bedaquiline-containing treatment regimens for multidrug-resistant tuberculosis (MDR-TB) and integrase strand transfer inhibitor (INSTI)-containing fixed dose combination antiretroviral therapy (ART) have radically transformed treatment for MDR-TB and HIV. However, without advances in adherence support, we may not realize the full potential of these therapeutics. The primary objective of this study is to compare the effect of adherence support interventions on clinical and biological endpoints using an adaptive randomized platform. METHODS This is a prospective, adaptive, randomized controlled trial comparing the effectiveness of four adherence support strategies on a composite clinical outcome in adults with MDR-TB and HIV initiating bedaquiline-containing MDR-TB treatment regimens and receiving ART in KwaZulu-Natal, South Africa. Trial arms include (1) enhanced standard of care, (2) psychosocial support, (3) mHealth using cellular-enabled electronic dose monitoring, and (4) combined mHealth and psychosocial support. The level of support will be titrated using a differentiated service delivery (DSD)-informed assessment of treatment support needs. The composite primary outcome will include survival, negative TB culture, retention in care, and undetectable HIV viral load at month 12. Secondary outcomes will include individual components of the primary outcome and quantitative evaluation of adherence on TB and HIV treatment outcomes. DISCUSSION This trial will evaluate the contribution of different modes of adherence support on MDR-TB and HIV outcomes with WHO-recommended all-oral MDR-TB regimens and ART in a high-burden operational setting. We will also assess the utility of a DSD framework to pragmatically adjust levels of MDR-TB and HIV treatment support. TRIAL REGISTRATION ClinicalTrials.gov NCT05633056. Registered on 1 December 2022.
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Affiliation(s)
- Jesse Ross
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Suite E101, 8th Floor, PH Building, 622 W. 168th Street, New York City, NY, 10032, USA
| | - Rubeshan Perumal
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Suite E101, 8th Floor, PH Building, 622 W. 168th Street, New York City, NY, 10032, USA
| | - Mbali Zulu
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Kevin Guzman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Suite E101, 8th Floor, PH Building, 622 W. 168th Street, New York City, NY, 10032, USA
| | - Boitumelo Seepamore
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- School of Applied Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Karl Reis
- Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA
| | - Hlengiwe Nyilana
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Senzo Hlathi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | | | - Ying Kuen K Cheung
- Department of Biostatistics, Columbia University Irving Medical Center, New York City, NY, USA
| | - K Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - Amrita Daftary
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Canada
| | - Jennifer R Zelnick
- Graduate School of Social Work, Touro University, New York City, NY, USA
| | - Kogieleum Naidoo
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Max R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Suite E101, 8th Floor, PH Building, 622 W. 168th Street, New York City, NY, 10032, USA.
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.
- Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY, USA.
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He J, Zhu Z, Sun M, Liu X, Yu J, Zhang L, Lu H. Barriers and facilitators to maintaining a high level of polypharmacy adherence in people living with HIV: A scoping review. Front Pharmacol 2023; 14:1013688. [PMID: 36937849 PMCID: PMC10017548 DOI: 10.3389/fphar.2023.1013688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
Objectives: With the prolongation of life span and increasing incidence of comorbidities, polypharmacy has become a challenge for people living with HIV/AIDS (PLWH). This review aimed to identify barriers and facilitators to maintaining a high level of polypharmacy adherence in people living with HIV/AIDS. Methods: Nine electronic databases were searched for studies from 1996 to October 2021. Studies were included if they were conducted with adults living with HIV/AIDS and reported barriers and facilitators to maintaining a high level of polypharmacy adherence. This review presents a conceptual framework model to help understand the barriers and facilitators. Results: Twenty-nine studies were included. The majority of publications were observational studies. Eighty specific factors were identified and further divided into five categories, including individual factors, treatment-related factors, condition-related factors, healthcare provider-related factors, and socioeconomic factors, based on the multidimensional adherence model (MAM). Conclusion: Eighty factors associated with polypharmacy adherence among people living with HIV/AIDS were identified and grouped into five major categories. Healthcare providers can make decisions based on the five categories of relevant factors described in this paper when developing interventions to enhance polypharmacy adherence. It is recommended that medications be evaluated separately and that an overall medication evaluation be conducted at the same time to prevent inappropriate polypharmacy use.
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Affiliation(s)
- Jiamin He
- School of Nursing, Fudan University, Shanghai, China
- Department of Nursing, Shanghai Public Health Clinical Center, Shanghai, China
| | - Zheng Zhu
- School of Nursing, Fudan University, Shanghai, China
- Fudan University Center for Evidence-based Nursing: A Joanna Briggs Institute Center of Excellence, Shanghai, China
- Rory Meyers College of Nursing, New York University, New York, NY, United States
- *Correspondence: Hongzhou Lu, ; Zheng Zhu,
| | - Meiyan Sun
- Department of Nursing, Shanghai Public Health Clinical Center, Shanghai, China
| | - Xiaoning Liu
- Department of Infectious Disease, National Clinical Research Center for Infectious Diseases, Shenzhen Third People’s Hospital, Shenzhen, Guangdong, China
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Junwen Yu
- School of Nursing, Fudan University, Shanghai, China
| | - Lin Zhang
- Department of Nursing, Shanghai Public Health Clinical Center, Shanghai, China
| | - Hongzhou Lu
- School of Nursing, Fudan University, Shanghai, China
- Department of Infectious Disease, National Clinical Research Center for Infectious Diseases, Shenzhen Third People’s Hospital, Shenzhen, Guangdong, China
- *Correspondence: Hongzhou Lu, ; Zheng Zhu,
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Boutilier JJ, Yoeli E, Rathauser J, Owiti P, Subbaraman R, Jónasson JO. Can digital adherence technologies reduce inequity in tuberculosis treatment success? Evidence from a randomised controlled trial. BMJ Glob Health 2022; 7:bmjgh-2022-010512. [PMID: 36455988 PMCID: PMC9716804 DOI: 10.1136/bmjgh-2022-010512] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/07/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Tuberculosis (TB) is a global health emergency and low treatment adherence among patients is a major barrier to ending the TB epidemic. The WHO promotes digital adherence technologies (DATs) as facilitators for improving treatment adherence in resource-limited settings. However, limited research has investigated whether DATs improve outcomes for high-risk patients (ie, those with a high probability of an unsuccessful outcome), leading to concerns that DATs may cause intervention-generated inequality. METHODS We conducted secondary analyses of data from a completed individual-level randomised controlled trial in Nairobi, Kenya during 2016-2017, which evaluated the average intervention effect of a novel DAT-based behavioural support programme. We trained a causal forest model to answer three research questions: (1) Was the effect of the intervention heterogeneous across individuals? (2) Was the intervention less effective for high-risk patients? nd (3) Can differentiated care improve programme effectiveness and equity in treatment outcomes? RESULTS We found that individual intervention effects-the percentage point reduction in the likelihood of an unsuccessful treatment outcome-ranged from 4.2 to 12.4, with an average of 8.2. The intervention was beneficial for 76% of patients, and most beneficial for high-risk patients. Differentiated enrolment policies, targeted at high-risk patients, have the potential to (1) increase the average intervention effect of DAT services by up to 28.5% and (2) decrease the population average and standard deviation (across patients) of the probability of an unsuccessful treatment outcome by up to 8.5% and 31.5%, respectively. CONCLUSION This DAT-based intervention can improve outcomes among high-risk patients, reducing inequity in the likelihood of an unsuccessful treatment outcome. In resource-limited settings where universal provision of the intervention is infeasible, targeting high-risk patients for DAT enrolment is a worthwhile strategy for programmes that involve human support sponsors, enabling them to achieve the highest possible impact for high-risk patients at a substantially improved cost-effectiveness ratio.
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Affiliation(s)
- Justin J Boutilier
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Erez Yoeli
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | | | | | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Jónas Oddur Jónasson
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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Harrison RE, Shyleika V, Falkenstein C, Garsevanidze E, Vishnevskaya O, Lonnroth K, Sayakci Ö, Sinha A, Sitali N, Skrahina A, Stringer B, Tan C, Mar HT, Venis S, Vetushko D, Viney K, Vishneuski R, Carrion Martin AI. Patient and health-care provider experience of a person-centred, multidisciplinary, psychosocial support and harm reduction programme for patients with harmful use of alcohol and drug-resistant tuberculosis in Minsk, Belarus. BMC Health Serv Res 2022; 22:1217. [PMID: 36180873 PMCID: PMC9523183 DOI: 10.1186/s12913-022-08525-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 08/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background Tuberculosis (TB) often concentrates in groups of people with complex health and social issues, including alcohol use disorders (AUD). Risk of TB, and poor TB treatment outcomes, are substantially elevated in people who have AUD. Médecins sans Frontières and the Belarus Ministry of Health have worked to improve treatment adherence in patients with multi-drug or rifampicin resistant (MDR/RR)-TB and harmful use of alcohol. In 2016, a person-centred, multidisciplinary, psychosocial support and harm reduction programme delivered by TB doctors, counsellors, psychiatrists, health-educators, and social workers was initiated. In 2020, we described patient and provider experiences within the programme as part of a wider evaluation. Methods We recruited 12 patients and 20 health-care workers, using purposive sampling, for in-depth individual interviews and focus group discussions. We used a participant-led, flexible, exploratory approach, enabling participants and the interviewer to shape topics of conversation. Qualitative data were coded manually and analysed thematically. As part of the analysis process, identified themes were shared with health-care worker participants to enable their reflections to be incorporated into the findings. Results Key themes related to the patients’ and practitioners experience of having and treating MDRTB with associated complex health and social issues were: fragility and despair and guidance, trust and health. Prejudice and marginalisation were global to both themes. Counsellors and other health workers built a trusting relationship with patients, enabling guidance through a multi-disciplinary approach, which supported patients to achieve their vision of health. This guidance was achieved by a team of social workers, counsellors, doctors and health-educators who provided professional and individualised help for patients’ illnesses, personal or interpersonal problems, administrative tasks, and job searches. Conclusions Patients with MDR/RR-TB and harmful use of alcohol faced complex issues during treatment. Our findings describe how person-centred, multi-disciplinary, psychosocial support helped patients in this setting to cope with these challenges and complete the treatment programme. We recommend that these findings are used to: i) inform programmatic changes to further boost the person-centred care nature of this program; and ii) advocate for this type of person-centred care approach to be rolled out across Belarus, and in contexts that face similar challenges. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08525-x.
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Affiliation(s)
| | | | | | | | | | - Knut Lonnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | - Alena Skrahina
- Republican Scientific and Practical Centre of Pulmonology and Tuberculosis (RSPCPT), Minsk, Republic of Belarus
| | | | | | | | | | - Dmitri Vetushko
- Republican Scientific and Practical Centre of Pulmonology and Tuberculosis (RSPCPT), Minsk, Republic of Belarus
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,School of Public Health, The University of Sydney, Sydney, Australia
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O’Donnell MR, Padayatchi N, Wolf A, Zelnick J, Daftary A, Orrell C, Nimmo C, Baldwin M, Boodhram R, Maharaj B, Amico KR, Friedland G. Bedaquiline Adherence Measured by Electronic Dose Monitoring Predicts Clinical Outcomes in the Treatment of Patients With Multidrug-Resistant Tuberculosis and HIV/AIDS. J Acquir Immune Defic Syndr 2022; 90:325-332. [PMID: 35195572 PMCID: PMC11077859 DOI: 10.1097/qai.0000000000002940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Novel regimens have revolutionized multidrug-resistant tuberculosis (MDR-TB) treatment; however, medication adherence remains challenging and poorly characterized. We hypothesized that bedaquiline adherence, measured using electronic dose monitoring, would predict MDR-TB treatment outcomes. SETTING This is a prospective cohort study conducted in KwaZulu-Natal, South Africa. METHODS Adults with MDR-TB and HIV initiating bedaquiline and on antiretroviral therapy (ART) were eligible. Separate electronic dose monitoring devices measured bedaquiline and ART adherence through 6 months, calculated as observed versus expected doses. Whole-genome sequencing was performed to identify bedaquiline resistance-associated variants. RESULTS From November 2016 through February 2018, 199 participants with MDR-TB and HIV were enrolled and followed up through treatment completion (median 17.2 months interquartile range 12.2-19.6). The median bedaquiline adherence was higher than ART adherence (97 vs. 89%, P < 0.001) but correlated (r2 = 0.68, P < 0.001). High bedaquiline adherence (≥90%) compared with lower adherence was associated with improved end of treatment successful outcome (83.4% vs. 46.3%, P < 0.001), decreased mortality (11.0% vs. 29.6% P = 0.004), and improved retention in care through end of treatment (94.5% vs. 79.6% P = 0.002). Modeling identified a highly significant but linear association between bedaquiline adherence and outcome. On multivariable analysis, bedaquiline adherence was independently associated with mortality and outcome. Bedaquiline resistance-associated variants were seen in 12% (7/57) of sequenced isolates (7% baseline, 5% emergent) with only 28.6% experiencing successful treatment outcome. CONCLUSIONS Bedaquiline adherence through 6 months independently predicted end of MDR-TB treatment outcome, but a specific bedaquiline adherence threshold was not identified. Interventions to optimize bedaquiline adherence are urgently needed to improve MDR-TB HIV treatment outcomes.
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Affiliation(s)
- Max R O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine
- Department of Epidemiology, Columbia University Medical Center, New York City, USA
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nesri Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York City, USA
| | - Jennifer Zelnick
- Graduate School of Social Work, Touro College and University System, New York City, USA
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University Toronto, Canada
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | | | - Camus Nimmo
- Division of Infection and Immunity, University College London, London, UK
- UCL Genetics Institute, University College London, London, UK
- Africa Health Research Institute, Durban, South Africa
| | - Matt Baldwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York City, USA
| | - Resha Boodhram
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Bhavna Maharaj
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - K. Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI, USA
- Kogieleum Naidoo CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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Bateman M, Wolf A, Chimukangara B, Brust JCM, Lessells R, Amico R, Boodhram R, Singh N, Orrell C, Friedland G, Naidoo K, Padayatchi N, O'Donnell MR. Adherence measured using electronic dose monitoring is associated with emergent antiretroviral resistance and poor outcomes in patients co-infected with HIV/AIDS and multidrug-resistant tuberculosis. Clin Infect Dis 2022; 75:1489-1496. [PMID: 35352097 PMCID: PMC9617578 DOI: 10.1093/cid/ciac232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Medication adherence is known to challenge treatment of HIV/AIDS and multidrug-resistant tuberculosis (MDR-TB). We hypothesized that electronic dose adherence monitoring (EDM) would identify an ART adherence threshold for emergent ART resistance and predict treatment outcomes in patients with MDR-TB and HIV on ART and bedaquiline-containing TB regimens. METHODS A prospective cohort of adults with MDR-TB and HIV, on ART and initiating MDR-TB treatment with bedaquiline, were enrolled at a public TB referral hospital in KwaZulu-Natal, South Africa (PRAXIS Study, Clinicaltrials.gov NCT03162107). Participants received separate EDM devices measuring adherence to bedaquiline and ART (nevirapine or lopinavir/ritonavir). Adherence was calculated cumulatively over six months. Participants were followed through completion of MDR-TB treatment. HIV genome sequencing was performed at baseline, 2 and 6 months on samples with HIV RNA ≥1000 copies/mL. FINDINGS From November 2016 through February 2018, 198 MDR-TB and HIV co-infected participants were enrolled and followed (median 17.2 months, IQR 12.2 - 19.6). Eleven percent had baseline ART resistance mutations, and 7.5% developed emergent ART resistance at 6 months. ART adherence was independently associated with both emergent ART resistance and mortality. Modeling identified a significant (p<0.001), but linear association between ART adherence and emergent resistance, suggesting a strong association without a specific threshold. INTERPRETATION Our findings highlight the need for ART resistance testing, especially in MDR-TB HIV co-infected patients, which is currently not standard of care in resource-limited settings. Despite short follow-up duration, reduced ART adherence was significantly associated with emergent resistance and increased mortality.
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Affiliation(s)
- Mark Bateman
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Benjamin Chimukangara
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland, USA.,CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - James C M Brust
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA
| | - Richard Lessells
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Rivet Amico
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Resha Boodhram
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nalini Singh
- King Dinuzulu Hospital Complex, Durban, South Africa
| | | | | | - Kogieleum Naidoo
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nesri Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Max R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA.,CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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Morojele NK, Shenoi SV, Shuper PA, Braithwaite RS, Rehm J. Alcohol Use and the Risk of Communicable Diseases. Nutrients 2021; 13:3317. [PMID: 34684318 PMCID: PMC8540096 DOI: 10.3390/nu13103317] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 01/12/2023] Open
Abstract
The body of knowledge on alcohol use and communicable diseases has been growing in recent years. Using a narrative review approach, this paper discusses alcohol's role in the acquisition of and treatment outcomes from four different communicable diseases: these include three conditions included in comparative risk assessments to date-Human Immunodeficiency Virus (HIV)/AIDS, tuberculosis (TB), and lower respiratory infections/pneumonia-as well as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) because of its recent and rapid ascension as a global health concern. Alcohol-attributable TB, HIV, and pneumonia combined were responsible for approximately 360,000 deaths and 13 million disability-adjusted life years lost (DALYs) in 2016, with alcohol-attributable TB deaths and DALYs predominating. There is strong evidence that alcohol is associated with increased incidence of and poorer treatment outcomes from HIV, TB, and pneumonia, via both behavioral and biological mechanisms. Preliminary studies suggest that heavy drinkers and those with alcohol use disorders are at increased risk of COVID-19 infection and severe illness. Aside from HIV research, limited research exists that can guide interventions for addressing alcohol-attributable TB and pneumonia or COVID-19. Implementation of effective individual-level interventions and alcohol control policies as a means of reducing the burden of communicable diseases is recommended.
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Affiliation(s)
- Neo K. Morojele
- Department of Psychology, University of Johannesburg, Johannesburg 2006, South Africa
| | - Sheela V. Shenoi
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, USA;
- Yale Institute for Global Health, Yale University, New Haven, CT 06520, USA
| | - Paul A. Shuper
- Centre for Addiction and Mental Health, Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute, Toronto, ON M5S 2S1, Canada; (P.A.S.); (J.R.)
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT 06269, USA
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Pretoria 0001, South Africa
| | - Ronald Scott Braithwaite
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, NYU Grossman School of Medicine, New York University, New York, NY 10013, USA;
| | - Jürgen Rehm
- Centre for Addiction and Mental Health, Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute, Toronto, ON M5S 2S1, Canada; (P.A.S.); (J.R.)
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON M5T 1R8, Canada
- Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, 01187 Dresden, Germany
- Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada
- Program on Substance Abuse, Public Health Agency of Catalonia, 08005 Barcelona, Spain
- Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
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