Community-based directly observed treatment for TB patients to improve HIV services: a cross-sectional study in a South African province

Perception, acceptability and challenges of digital adherence technology among TB healthcare workers

INTRODUCTION

Successful treatment of TB requires high levels of adherence to treatment. This has been found to be below optimal with directly observed therapy (DOT), and digital adherence technologies (DATs) offer a promising approach to non-adherence to medication and improving treatment outcomes. This study explores the perception, acceptability, and challenges of DATs among healthcare workers (HCWs).

METHODS

The study was conducted in eight states in Nigeria among Health Care workers involved in treating patients with TB. This was a descriptive cross-sectional study using an open questionnaire and analysed using IBM SPSS v25.

RESULTS

Twenty-three HCWs (95.8%) agreed that DATs helped them provide better support and counselling to their patients. All of them would recommend DATs to their patients and found it easy to explain them. Eleven (45.8%) of them were not able to use DATs on a few occasions; their reasons were poor network (n = 9, 37.5%) and (n = 1, 4.2%) power failure.

CONCLUSION

DATs help HCWs provide better support and care regarding real-time tracking of their patients' adherence to treatment and possibly reduction of attrition. This implies that DATs are a suitable alternative to DOT to help HCWs provide the best care and support to their patients towards achieving the End TB targets.

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

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.

Lung cancer awareness training experiences of community health workers in KwaZulu-Natal, South Africa

BACKGROUND

Lung cancer is the leading cause of cancer mortality worldwide. Awareness interventions in the developing world remain scarce. Community health workers (CHWs) are a critical component towards ensuring efficient delivery of healthcare services in low- and middle-income countries.

AIM

This study explored the experiences of CHWs of their training as lung cancer awareness intervention implementers.

SETTING

The study was conducted in a resource-poor setting, with CHWs from previously disadvantaged communities.

METHODS

On the last day of training, 10 CHWs were requested to voluntarily participate in a focus group discussion regarding their experiences of the training, utilising a discussion guide.

RESULTS

The participants expressed positive experiences with the training. They cited the amenable and conducive learning environment established by the facilitator. The participants felt empowered through the newly acquired knowledge and wanted to help their communities. However, some participants expressed a desire to have other forms of learning incorporated in future training. The participants were also cognisant of existing gaps in their own knowledge that could be elaborated upon in preparation for potential questions by the community. Some participants confirmed their role as agents of change.

CONCLUSION

The authors propose large-scale intervention studies of lung cancer awareness utilising the CHW programme to gather conclusive evidence regarding their effectiveness at a community level.Contribution: This article provides insight into the training of community health workers on lung cancer awareness and future research on the integration of the intervention into already existing programmes.

Lack of latent tuberculosis (TB) screening and delay in anti-retroviral therapy initiation in HIV-TB co-infection: an 11-year study in an intermediate TB-burden country

OBJECTIVES

To examine the prevalence and characteristics of HIV-tuberculosis (TB) co-infected patients in Singapore, an intermediate TB-burden country.

METHODS

Retrospective data across 11 years was obtained from the National University Hospital (NUH), a quaternary hospital and the National Centre for Infectious Diseases (NCID), the national HIV center.

RESULTS

From December 2005 to December 2016, 4015 HIV-infected patients were managed at NUH and NCID, of whom, respectively, 48 and 272 were diagnosed with active TB disease. Only 2 patients (0.6%) were screened for latent TB infection on HIV diagnosis. Mean CD4 count at TB diagnosis was 125.0 ± 153.9 cells/mm³. More patients with HIV diagnosed ≥6 weeks before TB (41%) were associated with CD4 counts >200 cells/mm³ than patients with TB diagnosed ≥6 weeks before HIV (2%). Of 124 (38.6%) HIV-TB patients with CD4 count ≤50 cells/mm³, only 18 (14.2%) started anti-retroviral therapy (ART) in <2 weeks. Of patients with pulmonary TB, 33.5% had normal chest x-ray.

CONCLUSIONS

Latent TB infection screening in HIV-infected patients is low, and ART initiation is delayed in HIV-TB patients with CD4 ≤50 cells/mm³. Pulmonary TB patients with HIV can be infectious despite normal chest x-ray. Clinical practices can be further improved to benefit HIV-TB patients.

Tuberculosis and type 2 Diabetes Mellitus (TB-DM) comorbidity care: Barriers from the patients' perspective

OBJECTIVE

This study aims to explore the experiences of TB-DM patients for the service barriers encountered in achieving the expected outcomes.

METHOD

A qualitative study was conducted between June-August 2019. TB-DM patients were identified from community health centers, and hospital TB registers Yogyakarta City, Indonesia. Fourteen adult TB-DM patients were purposively selected using criterion sampling. They were those who had been cured or already completed the intensive phase of TB treatment from 2018 to 2019. In-depth interviews were carried out using interview guides and tape-recorded. Thematic analysis was used to analyze the verbatim transcripts.

RESULTS

Four themes were identified: health services-related barriers, patient-related barriers, health provider-patients interaction-related barriers, and strategies to resolve the barriers.

CONCLUSION

TB-DM patients faced a cascade of barriers with accessing TB-DM care and supports. Re-orienting the health care system for more integrated chronic care readiness and improving patients' capacity is critical to improving the quality of care.

Masculinity, resources, and retention in care: South African men's behaviors and experiences while engaged in TB care and treatment

RATIONALE

Globally, the prevalence of tuberculosis (TB) disease is significantly higher among men compared to women. This is compounded by men's poorer uptake of TB testing and treatment, and worse outcomes for smear conversion and successful treatment completion compared to women; in South Africa specifically, TB accounts for a large portion of sex-specific life expectancy differences.

OBJECTIVE

To understand men's unique barriers to accessing care and their needs while engaged in TB treatment, we conducted a qualitative study with men currently in or who recently completed TB treatment to understand how social norms for masculinity influence resource access and health behaviors, and in turn affect their engagement in care.

METHODS

We interviewed 31 men using a semi-structured protocol, with domains including: social network composition and support; TB illness; and testing, treatment, and clinical care experiences. Interviews were analyzed using a constant comparison approach to identify resources and how these are exchanged within men's social networks for TB care.

RESULTS

We found that men's prioritizing of work ensured food security and maintenance of masculinity norms, but delayed seeking and engagement in care. Once in treatment, men found it difficult both to negotiate clinic hours and work schedules and to navigate clinic environments without being labeled as weak. To mitigate individual resource gaps and losses, men typically accessed women family members who provided key resources (e.g., food, money, and emotional encouragement). Masculine identification with fatherhood was a key motivator to remain engaged in TB care and treatment. Loss from care was facilitated by isolation and limited access to social network resources.

CONCLUSION

To improve men's engagement in care and successful treatment outcomes, interventions that leverage their social networks and build upon existing resources should be strongly considered.

Crowding has consequences: Prevention and management of COVID-19 in informal urban settlements

COVID-19 spreads via aerosols, droplets, fomites and faeces. The built environment that facilitates crowding increases exposure and hence transmission of COVID-19 as evidenced by outbreaks in both cool-dry and hot-humid climates, such as in the US prison system and dormitories in Singapore, respectively. This paper explores how the built environment influences crowding and COVID-19 transmission, focusing on informal urban settlements (slums). We propose policy and practice changes that could reduce COVID-19 transmission. There are several issues on how COVID-19 affects informal urban settlements. Slum populations tend to be younger than the overall population. Lower numbers of older people lessen the morbidity and mortality of the pandemic in slum areas. Second, many slum populations are highly mobile. By returning to their ancestral villages residents can avoid the risks of overcrowding and reduce the population density in a given area but may spread COVID-19 to other areas. Third, detection and registration of COVID-19 cases depends on patients presenting to health care providers. If the risk of visiting a health care centre outweighs the potential benefits patients may prefer not to seek treatment. The control and prevention of COVID-19 in informal urban settlements starts with organizing community infrastructure for diagnosis and treatment and assuring that basic needs (food, water, sanitation, health care and public transport) are met during quarantine. Next, community members at highest risk need to be identified and protected. Low-income, informal settlements need to be recognized as a reservoir and source for persistent transmission. Solutions to overcrowding must be developed for this and future pandemics. In view of the constant risk that slums present to the entire population decisive steps need to be taken to rehabilitate and improve informal settlements, while avoiding stigmatization.

Video directly observed therapy for supporting and monitoring adherence to tuberculosis treatment in Uganda: a pilot cohort study

Introduction

Nonadherence to treatment remains an obstacle to tuberculosis (TB) control worldwide. The aim of this study was to evaluate the feasibility of using video directly observed therapy (VDOT) for supporting TB treatment adherence in Uganda.

Methods

From May to December 2018, we conducted a pilot cohort study at a TB clinic in Kampala City. We enrolled patients aged 18–65 years with ≥3 months remaining of their TB treatment. Participants were trained to use a smartphone app to record videos of medication intake and submit them to a secured system. Trained health workers logged into the system to watch the submitted videos. The primary outcome was adherence measured as the fraction of expected doses observed (FEDO). In a secondary analysis, we examined differences in FEDO by sex, age, phone ownership, duration of follow-up, reasons for missed videos and patients' satisfaction at study exit.

Results

Of 52 patients enrolled, 50 were analysed. 28 (56%) were male, the mean age was 31 years (range 19–50 years) and 35 (70%) owned smartphones. Of the 5150 videos expected, 4231 (82.2%) were received. The median FEDO was 85% (interquartile range 66%–94%) and this significantly differed by follow-up duration. Phone malfunction, uncharged battery and VDOT app malfunctions were the commonest reasons for missed videos. 92% of patients reported being very satisfied with using VDOT.

Conclusion

VDOT was feasible and acceptable for monitoring and supporting TB treatment. It resulted in high levels of adherence, suggesting that digital technology holds promise in improving patient monitoring in Uganda.

Video directly observed therapy is feasible and acceptable for supporting and monitoring TB treatment adherence in a low-resource setting like Uganda. Digital health interventions hold promise as alternative methods for improving patient care.http://bit.ly/2Hxnvwu