A qualitative evaluation of hospital versus community-based management of patients on injectable treatments for tuberculosis

Letting the patients speak: an in-depth, qualitative research-based investigation of factors relevant to health-related quality of life in real-world patients with hereditary angioedema using subcutaneous C1 inhibitor replacement therapy

Background

While many studies of effective hereditary angioedema (HAE) therapy have demonstrated improved health-related quality of life (HRQoL) using validated instruments, specific reasons behind the improved scores have never been investigated using qualitative methods. A non-interventional, qualitative research study was designed to investigate the reasons for improvements in HRQoL while using effective prophylaxis, in this case subcutaneous C1INH (C1INH[SC]) replacement therapy.

Methods

Adult patients with HAE-C1INH type 1 or 2 who had been using C1INH(SC) for ≥ 3 consecutive months were recruited through four HAE specialty practices in the US to participate in a 60-min phone interview performed by a trained qualitative research specialist (ICON plc) using a semi-structured interview guide with open-ended questions developed with the Angioedema Quality of Life (AE-QoL) items in mind. Interview transcripts were analyzed using thematic analysis methods to identify concepts (specific symptoms/impacts) and themes (higher-level categories grouping related concepts). A cross-mapping exercise was performed between interview-identified concepts and items included in the AE-QoL.

Results

Fourteen patients were interviewed and included in the analysis (age range, 28–82 years [mean 47.5 years]; 64% female; 93% white). In 10 interviews, patients mentioned having no or nearly no HAE attacks, no longer feeling limited by HAE, less HAE-related anxiety/worry and depression, an improved ability to travel, fewer emergency room/hospital visits, and ease of administration of C1INH(SC), including not requiring assistance from others. Other commonly expressed concepts included: increased feelings of confidence, independence, optimism, and normalcy; less absence from work/school; better productivity; improved sleep and energy; healthier family relationships; and improved cognition. While all AE-QoL items emerged from patient interviews, a number of identified concepts were not addressed by the AE-QoL, including sensitivity to various potential attack-triggers (e.g., stress/anxiety, sports), attack frequency, not having to cancel social plans, improvements in ability to perform day-to-day tasks, and a lower burden from medical visits.

Conclusions

From these interviews, a large number of common themes and concepts emerged: a greater sense of freedom and normalcy, increased productivity, and improved interpersonal relationships while using convenient and effective prophylaxis. These findings provide insights into real-world experiences and the many facets of HRQoL that are important to patients with HAE-C1INH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13223-021-00550-5.

"Dispense antiretrovirals daily!" restructuring the delivery of HIV services to optimize antiretroviral initiation among men in Malawi

BACKGROUND

Gender disparities exist in the scale-up and uptake of HIV services with men being disproportionately under-represented in the services. In Eastern and Southern Africa, of the people living with HIV infection, more adult women than men were on treatment highlighting the disparities in HIV services. Delayed initiation of antiretroviral treatment creates a missed opportunity to prevent transmission of HIV while increasing HIV and AIDS-associated morbidity and mortality. The main objective of this study was to assess the strategies that men prefer for Antiretroviral Therapy (ART) initiation in Blantyre, Malawi.

METHODS

This was a qualitative study conducted in 7 Health facilities in Blantyre from January to July 2017. We selected participants following purposive sampling. We conducted 20 in-depth interviews (IDIs) with men of different HIV statuses, 17 interviews with health care workers (HCWs), and 14 focus group discussions (FGDs) among men of varying HIV statuses. We digitally recorded all the data, transcribed verbatim, managed using NVivo, and analysed it thematically.

RESULTS

Restructuring the delivery of antiretroviral (ARVs) treatment and conduct of ART clinics is key to optimizing early initiation of treatment among heterosexual men in Blantyre. The areas requiring restructuring included: Clinic days by offering ARVs daily; Clinic hours to accommodate schedules of men; Clinic layout and flow that preserves privacy and establishment of male-specific clinics; ARV dispensing procedures where clients receive more pills to last them longer than 3 months. Additionally there is need to improve the packaging of ARVs, invent ARVs with less dosing frequency, and dispense ARVs from the main pharmacy. It was further suggested that the test-and-treat strategy be implemented with fidelity and revising the content in counseling sessions with an emphasis on the benefits of ARVs.

CONCLUSION

The success in ART initiation among men will require a restructuring of the current ART services to make them accessible and available for men to initiate treatment. The inclusion of people-centered approaches will ensure that individual preferences are incorporated into the initiation of ARVs. The type, frequency, distribution, and packaging of ARVs should be aligned with other medicines readily available within a health facility to minimize stigma.

Proteomic Analysis of Differentially Expressed Proteins in Mycobacterium Tuberculosis-Infected Macrophages

Background:

Mycobacterium tuberculosis (MTB) and Mycobacterium avium (MA) are intracellular parasitic bacteria. The biological characteristics of MA and MTB are very similar and need to be identified.

Objective:

The study aims to better understand how MTB survives in macrophages and the different pathogenic mechanisms of MTB and MA.

Methods:

The Tandem Mass Tag (TMT) and liquid chromatography-tandem mass spectrometry (LCMS/ MS) were used for analysis of the differentially expressed proteins in MTB-infected macrophages and MA-infected macrophages.

Results:

A total of 682 proteins were found to be differentially expressed in MTB-infected cells in comparison with MA-infected cells. Among these, 10 proteins (O60812, P06576, O43660-2, E9PL10, O00442, M0R050, Q9H8H0, Q9BSJ8, P41240 and Q8TD57-3) were down-regulated in MTB-infected cells, and M0R050, O00442, Q9H8H0, O60812 and O43660 are interactive proteins which participate in a multitude of cellular RNA processing.

Conclusion:

The five down-regulated proteins (M0R050, O00442, Q9H8H0, O60812 and O43660) might repress the synthesis of some resistant proteins in MTB-infected cells to promote MTB survival in macrophages.

Delivery of long-term-injectable agents for TB by lay carers: pragmatic randomised trial

BACKGROUND

People with recurrent or drug-resistant TB require long courses of intramuscular injections. We evaluate a novel system in which patient-nominated lay carers were trained to deliver intramuscular injections to patients in their own homes.

METHODS

A pragmatic, individually randomised non-inferiority trial was conducted at two hospitals in Malawi. Adults starting TB retreatment were recruited. Patients randomised to the intervention received home-based care from patient-nominated lay people trained to deliver intramuscular streptomycin. Patients receiving standard care were admitted to hospital for 2 months of streptomycin. The primary outcome was successful treatment (alive and on treatment) at the end of the intervention.

RESULTS

Of 456 patients screened, 204 participants were randomised. The trial was terminated early due to futility. At the end of the intervention, 97/101 (96.0%) in the hospital arm were still alive and on treatment compared with 96/103 (93.2%) in the home-based arm (risk difference -0.03 (95% CI -0.09 to 0.03); p value 0.538). There were no differences in the proportion completing 8 months of anti-TB treatment; or the proportion experiencing 2-month sputum culture conversion. The mean cost of hospital-based management was US$1546.3 per person, compared to US$729.2 for home-based management. Home-based care reduced risk of catastrophic household costs by 84%.

CONCLUSIONS

Although this trial failed to meet target recruitment, the available data demonstrate that training patient-nominated lay people has potential to provide a feasible solution to the operational challenges associated with delivering long-term-injectable drugs to people with recurrent or drug-resistant TB in resource-limited settings, and substantially reduce costs. Further data under operational conditions are required.

TRIAL REGISTRATION NUMBER

ISRCTN05815615.

Disrupting a cycle of mistrust: A constructivist grounded theory study on patient-provider trust in TB care

Despite the importance of patient-provider trust identified in earlier research on tuberculosis (TB) care, there has been no in-depth exploration of its determinants and how it affects TB patient experiences. We conducted a constructivist grounded theory study to explore the process of patient-provider trust in the context of TB care. This study took place in Cape Town, South Africa, an urban setting with a high prevalence of TB, and where treatment for TB is provided free-of-charge. We used theoretical sampling to select participants (TB patients and providers) from four public primary care clinics and one public TB hospital between Dec. 2015 to May 2017. We conducted in-depth, semi-structured interviews with 33 adult TB patients and 26 TB providers (including doctors, nurses, counsellors and community health workers). Interviews were transcribed and analyzed using a constant comparative approach. Our resultant theory, entitled "Disrupting a cycle of mistrust", describes a cycle of mistrust between TB patients and their providers that is grounded in health system norms and guidelines, and in subsequent provider and patient actions. This cycle is disrupted when providers develop and demonstrate trust towards their patients, which in turn builds patient trust in them and promotes positive treatment experiences. This theoretical model demonstrates the connection between structure (health system, local norms) and agency (individual practices and behaviours), and shows how the rigidity of current global TB treatment practices undermines opportunities to establish patient-provider trust. The model should guide future research on measuring and building patient-provider trust in TB care, and motivate for a new TB treatment paradigm that focuses more on patient-provider trust, and less on patient supervision and mistrust.