Socio-economic drivers of drug-resistant tuberculosis in Africa: a scoping review

Prevalence and Factors Associated with Substance Use Among Patients with Tuberculosis in Uganda

Background: Substance use can negatively impact treatment adherence and health outcomes, thus exacerbating the burden of the disease. This study determined the prevalence and factors associated with substance use among patients with TB disease in Kampala, Uganda. Methods: This was a cross-sectional study of 144 patients with drug-susceptible TB enrolled from July 2020 to March 2021 across five health facilities in Kampala. Eligible participants were 18-65 years old, diagnosed with TB, and had initiated treatment for <= one month. Exclusions included drug-resistant TB, severe illness, or impairments affecting study participation. Data on socio-demographics, substance use, and clinical characteristics were collected using a semi-structured questionnaire. Self-reported substance use was the outcome of interest. Descriptive statistics and simple logistic regression analyses were performed for factors associated with substance use. Stata version 18.0 was used for analysis. Results: The participants had a median age of 34 years (IQR: 25.5 - 45.0); 50% were female and 31.9% were HIV infected. The prevalence of any substance use was 20.8% among TB patients. Alcohol use was the predominant substance (18.1%), followed by marijuana (2.8%) and tobacco (2.1%). Males were more likely than females to use any substances (COR: 2.38, 95% CI: 1.02 - 5.56, p=0.055), as were HIV-infected persons (COR: 3.20, 95% CI: 1.40 - 7.34, p=0.006), and those affiliated with the Catholic religion (COR: 3.50, 95% CI: 1.06 - 11.60, p=0.040). Conclusion: Our study found a relatively high level of substance use among persons with TB. TB-HIV co-infected persons should be particularly targeted with interventions to minimize the negative health effects of substance use.

Drug-Resistant Tuberculosis in Rural Eastern Cape, South Africa: A Study of Patients' Characteristics in Selected Healthcare Facilities

This study investigated the characteristics and outcomes of drug-resistant tuberculosis patients in selected rural healthcare facilities in the Eastern Cape, South Africa. A retrospective review of clinical records from 456 patients, covering the period from January 2018 to December 2020, revealed a statistically significant relationship between DR-TB types and age groups (Chi-square statistic: 30.74, p-value: 0.015). Younger adults (19-35 years) and middle-aged adults (36-50 years) are more frequently affected by RR-TB and MDR-TB, which are the most prevalent forms of DR-TB. Less common types, including Pre-XDR, XDR, and INH TB, were observed in smaller numbers. The study suggests that DR-TB imposes a heavy burden on the working age population. Gender analysis shows that while the frequency of DR-TB differs between males and females, the percentage distribution of DR-TB types is relatively equal. Both genders are predominantly affected by RR-TB and MDR-TB, which together account for nearly 90% of cases. Pre-XDR, XDR, and INH-resistant TB are much less common, comprising only a small percentage of cases in both males and females. High-risk behaviors such as smoking and drinking are linked to a wider diversity of DR-TB types, while occupations like mining and prison work show higher rates of RR-TB and MDR-TB. In HIV-positive individuals, DR-TB is more common, but the distribution of DR-TB types between HIV-positive and negative groups shows no statistically significant difference. However, HIV-positive individuals have a 20% lower survival rate (65%) compared to HIV-negative patients (85%). Financial stability and comorbidities also significantly influence outcomes, with patients having stable income and fewer high-risk comorbidities experiencing better survival and treatment outcomes. The findings underscore the importance of addressing socioeconomic disparities and strengthening healthcare infrastructure to improve DR-TB treatment outcomes in rural Eastern Cape.

The epidemiology, transmission, diagnosis, and management of drug-resistant tuberculosis-lessons from the South African experience

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.

Decoding drug resistance in Mycobacterium tuberculosis complex: genetic insights and future challenges

INTRODUCTION

Tuberculosis (TB), particularly its drug-resistant forms (MDR-TB and XDR-TB), continues to pose a significant global health challenge. Despite advances in treatment and diagnosis, the evolving nature of drug resistance in Mycobacterium tuberculosis (MTB) complicates TB eradication efforts. This review delves into the complexities of anti-TB drug resistance, its mechanisms, and implications on healthcare strategies globally.

AREAS COVERED

We explore the genetic underpinnings of resistance to both first-line and second-line anti-TB drugs, highlighting the role of mutations in key genes. The discussion extends to advanced diagnostic techniques, such as Whole-Genome Sequencing (WGS), CRISPR-based diagnostics and their impact on identifying and managing drug-resistant TB. Additionally, we discuss artificial intelligence applications, current treatment strategies, challenges in managing MDR-TB and XDR-TB, and the global disparities in TB treatment and control, translating to different therapeutic outcomes and have the potential to revolutionize our understanding and management of drug-resistant tuberculosis.

EXPERT OPINION

The current landscape of anti-TB drug resistance demands an integrated approach combining advanced diagnostics, novel therapeutic strategies, and global collaborative efforts. Future research should focus on understanding polygenic resistance and developing personalized medicine approaches. Policymakers must prioritize equitable access to diagnosis and treatment, enhancing TB control strategies, and support ongoing research and augmented government funding to address this critical public health issue effectively.

Lived experiences of patients and families with decentralised drug-resistant tuberculosis care in the Eastern Cape, South Africa

BACKGROUND

South Africa adopted the decentralised Drug Resistant Tuberculosis (DR-TB) care model in 2011 with a view of improving clinical outcomes.

AIM

This study explores the experiences and perceptions of patients and family members on the effectiveness of a decentralised community DR-TB care model in the Oliver Reginald Kaizana (OR) Tambo district municipality of the Eastern Cape, South Africa.

METHOD

In this phenomenological qualitative research design, a semi-structured interview with prompts was conducted on 30 participants (15 patients and 15 family members). Framework approach to thematic content analysis was adopted for qualitative data analysis.

RESULTS

Four themes emerged from the patients' interviews: adequate knowledge of DR-TB and its transmission, fear of death and isolation, long travel distances, and exorbitant transportation cost. A 'ready' health system influenced the effectiveness of community DR-TB management, while interviews with family members yielded five themes: misconceptions about DR-TB, rapid diagnosis and adherence counselling, long travel distances, activated healthcare workers, and little role of traditional healer.

CONCLUSION

A perceived effectiveness of a community DR-TB care model in the OR Tambo district was demonstrated through the quality and comprehensiveness of care rendered by a 'ready' health system with activated health care workers (HCWs) who provided robust support and adequate knowledge of DR-TB and its treatment/side effects. However, misconceptions about DR-TB, long travel distances to treatment facilities, high cost of transportation and stigma remained challenging for most patients and family members.Contribution: This study provides insight into the lived experiences of a decentralised community DR-TB care model in the OR Tambo district in 2020.

Geographic distribution and predictors of diagnostic delays among possible TB patients in Uganda

BACKGROUND

Understanding the geographic distribution and factors associated with delayed TB diagnosis may help target interventions to reduce delays and improve patient outcomes.

METHODS

We conducted a secondary analysis of adults undergoing TB evaluation within a public health demonstration project in Uganda. Using Global Moran's I (GMI) and Getis-Ord GI* statistics, we evaluated for residential clustering and hotspots associated with patient-related and health system-related delays. We performed multivariate logistic regression to identify individual predictors of both types of delays.

RESULTS

Of 996 adults undergoing TB evaluation (median age: 37 years, IQR 28-49), 333 (33%) experienced patient delays, and 568 (57%) experienced health system delays. Participants were clustered (GMI 0.47-0.64, P ⩽ 0.001) at the sub-county level, but there were no statistically significant hotspots for patient or health system delays. Married individuals were less likely to experience patient delays (OR 0.6, 95% CI 0.48-0.75; P < 0.001). Those aged 38-57 years (OR 1.2, 95% CI 1.07-1.38; P = 0.002) were more likely than those aged ⩾58 years to experience patient delays. Knowledge about TB (OR 0.8, 95% CI 0.63-0.98; P = 0.03) protected against health system delays.

CONCLUSIONS

We did not identify geographic hotspots for TB diagnostic delays. Instead, delays were associated with individual factors such as age, marital status and TB knowledge.

Knowledge, attitude and preventative practice of tuberculosis in rural communities of Dikgale, Mamabolo and Mothiba health and demographic surveillance system in Limpopo province, South Africa

BACKGROUND

Tuberculosis continues to be a serious public health issue. To reduce the transmission of the disease, it is imperative to address the major obstacle of inadequate understanding regarding the causes, risk factors, treatments, and prevention of pulmonary TB. The study assessed knowledge, attitude, and preventative practices of tuberculosis among community members in Dikgale, Mamabolo and Mothiba (DIMAMO) Health Demographic Surveillance system, Limpopo Province South Africa.

METHODS

A cross-sectional clinic-based survey involving 360 participants was conducted at clinics at Dikgale, Mamabolo and Mothiba (DIMAMO) Health and Demographic Surveillance System. A standardised questionnaire on socio-demographic, knowledge, attitude and preventative practices towards tuberculosis based on (WHO) KAP-TB template guidelines was used to collect data. Descriptive statistics on Statistical Package for Social Sciences (SPSS) version 27.0 was used to analyse data.

RESULTS

The results of the cross-sectional survey on KAP-TB illustrated that the participants have good knowledge, attitude, and perception of TB. Majority of the participants (n = 270, 75%) had good general knowledge, while (n = 90, 25%) had poor knowledge about TB. However, the study reports (n = 57, 15.6%) having knowledge of causative agents of TB. Participants showed a favourable attitude toward people who are infected with TB. 87% showed a favourable attitude while only 12.46% showed an unfavourable attitude towards TB. Participants showed a good practice of (71.7%) while (28.3%) of participants had poor practice towards TB.

CONCLUSION

Health education interventions programme on TB needs to be intensified among the community members to improve TB awareness and reduce transmission. Focused educational interventions on TB aetiology and mode of transmission are required to increase TB preventative practices and improve health-seeking behaviour among community members.

Time-to-Treatment Initiation in a Decentralised Community-Care Model of Drug-Resistant Tuberculosis Management in the OR Tambo District Municipality of South Africa

BACKGROUND

Drug-resistant tuberculosis (DR-TB) continues to challenge global efforts toward eradicating and having a tuberculosis-free world. Considering the high early mortality, especially among HIV-infected individuals, early diagnosis and prompt initiation of effective treatment are needed to significantly reduce mortality and halt transmission of DR-TB in the community.

AIM

This study aims to assess the effectiveness of a community DR-TB care model with the specific objective of determining the Time-to-treatment initiation of DR-TB among patients in the OR Tambo district municipality.

METHODS

A prospective cohort study of patients with DR-TB was conducted in the OR Tambo district municipality of Eastern Cape Province, South Africa. Patients were enrolled as they presented for treatment initiation at the decentralised facilities following a diagnosis of DR-TB and compared with a centralised site.

RESULTS

A total of 454 DR-TB patients from six facilities between 2018 and 2020 were included in the analysis. The mean age was 37.54 (SD = 14.94) years. There were slightly more males (56.2%) than females (43.8%). Most of the patients were aged 18-44 years (67.5%), without income (82.3%). Results showed that slightly over thirteen percent (13.4%) of patients initiated treatment the same day they were diagnosed with DR-TB, while 36.3% were on the time-to-treatment target of being initiated within 5 days. However, about a quarter (25.8%) of patients failed to initiate treatment two weeks after diagnosis. Time-to-treatment initiation (TTTI) varied according to the decentralised sites, with progressive improvement with each successive year between 2018 and 2021. No demographic factor was significantly associated with TTTI.

CONCLUSION

Despite rapid diagnosis, only 36% of patients were initiated on treatment promptly. Operational challenges remained, and services needed to be reorganised to maximise the exceptional potentials that a decentralised community DR-TB care model brings.

Treatment of Infection as a Core Strategy to Prevent Rifampicin-Resistant/Multidrug-Resistant Tuberculosis

An estimated 19 million people are infected with rifampicin-resistant/multidrug-resistant strains of tuberculosis worldwide. There is little done to prevent these individuals from becoming sick with RR/MDR-TB, a disease that is associated with high rates of morbidity, mortality, and suffering. There are multiple phase III trials currently being conducted to assess the effectiveness of treatment of infection (i.e., "preventive therapy") for RR/MDR-TB, but their results are likely years away. In the meantime, there is sufficient evidence to support a more comprehensive management of people who have been exposed to RR/MDR-TB so that they can maintain their health. We present a patient scenario and share our experience in implementing a systematic post-exposure management program in South Africa with the goal of inspiring similar programs in other high-burden RR/MDR-TB settings.

Drug-Resistant Tuberculosis Stigma Among HealthCare Workers Toward the Development of a Stigma-Reduction Strategy: A Scoping Review

Drug-resistant tuberculosis (DRTB) is a growing concern worldwide. The poor rate of service delivery exacerbates the severity, leading to an increase in community transmission, which is further amplified by stigma. Health care workers (HCWs) are at the forefront lines of service delivery; their efforts are suspected of resulting in stigmatization, negatively impacting patient-centered care. However, little is known about DRTB-related stigma among these HCWs, and interventions are limited. Our scoping review is significant because it provides an overview of the DRTB stigma confronting HCWs and informs subsequent stigma-reduction initiatives. Utilizing Arksey and O'Malley framework, we exhaustively searched electronic databases for relevant English-language studies published from 2010 to 2022, identifying the drivers and facilitators of DRTB-related stigma among HCWs from high-TB and -DRTB burden countries, and compiling recommendations that could reduce DRTB stigma. From 443 de-duplicated papers, 11 articles on HCWs' DRTB-related stigma were reviewed and synthesized. Fear was mentioned across included articles as a stigma driver. Other reported stigma drivers identified included feelings of discrimination, isolation, danger, lack of support, shame, and stress. Poor infection control (IC) was the leading stigma facilitator. Other stigma facilitators identified were differing IC interpretations, workforce culture, and workplace inequality facilitating to stigmatization of HCWs. Three key recommendations identified were addressing infection control issues; increase the competence of healthcare workers; and provide psychosocial assistance, emphasizing HCW safety during DRTB activities. DRTB stigma among HCWs is multifaceted, largely driven by fear and facilitated by varying implementation or interpretations of policies within the workplace. Making HCWs feel safe while conducting DRTB activities is a priority issue that should be addressed by improving IC, training and psychosocial support. More studies investigating country-specific and multilevel DRTB-related stigma among HCWs are required to inform the development of an effective stigma intervention strategy.

Host-directed therapy against tuberculosis: Concept and recent developments

Tuberculosis (TB) continues to remain at the forefront of the infectious disease burden globally, albeit with some aberrations during the COVID-19 pandemic. Among many factors, the emergence of drug resistance or antimicrobial resistance (AMR) has necessitated a renewed focus on developing novel and repurposed drugs against TB. Host-directed therapy (HDT) has emerged as an attractive alternative and a complementary strategy to the conventional antibiotic-based therapy of tuberculosis since HDT enjoys the advantage of disarming the pathogen of its ability to develop drug resistance. Considering the imminent threat of AMR across the spectrum of bacterial pathogens, HDT promises to overcome the drug shortage against superbugs. While all these make HDT a very attractive strategy, identifying the right set of host targets to develop HDT remains a challenge, despite remarkable development in the field over the past decade. In this review, we examine the host mechanisms, that either inadvertently or through targeted perturbation by the pathogen, help TB pathogenesis, and we discuss the latest developments in the targeting of some of the key pathways to achieve newer TB therapeutics.

At the interface between the formal and informal, the actual and the real: a realist study protocol for governance and accountability practices in urban settings focusing on adolescent sexual and reproductive health and rights

BACKGROUND

This paper presents the protocol of a study that aims at exploring how different multi-level governance arrangements impact on sexual and reproductive health of adolescents living in informal settlements. The overall objective of this study is to contribute to a better understanding of the causal chains underlying accountability in sexual and reproductive health for adolescent girls and young women living in urban informal settlements in low-and middle-income countries.

METHODS

The overarching methodology is realist evaluation. The study adopts a case study design, through which governance and accountability practices in Mumbai, Delhi, Cotonou and Kampala will be examined. Different social science methods to develop and test a programme theory will be used. Heuristic tools for the analysis of the accountability ecosystem and mapping of governance arrangements, drawing from contextual political analysis and critical realism, will be developed in order to identify the intervention-context-actor-mechanism-outcome configurations.

DISCUSSION

The methodological approach is geared towards building robust case-based explanation with due attention to context and the roles of different actors. The combination of different social science methods will lead us to a better grasp of the inherently political nature of social accountability.

Pragmatic Management of Drug-Resistant Tuberculosis: A Qualitative Analysis of Human Resource Constraints in a Resource-Limited Country context-Ethiopia

Objectives: Existing evidence suggests that drug-resistant tuberculosis (DR-TB) remains a huge public health threat in high-burden TB countries such as Ethiopia. The purpose of this qualitative study was to explore the challenges of healthcare workers (HCWs) involved in providing DR-TB care in Addis Ababa, Ethiopia.

Methods: We conducted in-depth interviews with 18 HCWs purposively selected from 10 healthcare facilities in Addis Ababa, Ethiopia. We then transcribed the audiotaped interviews, and thematically analysed the transcripts using Braun and Clark’s reflexive thematic analysis framework.

Results: We identified five major themes: 1) inadequate training and provision of information on DR-TB to HCWs assigned to work in DR-TB services, 2) fear of DR-TB infection, 3) risk of contracting DR-TB, 4) a heavy workload, and 5) resource limitations.

Conclusion: Our findings highlight major human resource constraints that current DR-TB care policies need to foresee and accommodate. New evidence and best practices on what works in DR-TB care in such resource-limited countries are needed in order to address implementation gaps and to meet global TB strategies.