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Kamchedzera W, Quaife M, Msukwa-Panje W, Burke RM, Macpherson L, Kumwenda M, Twabi HH, Quartagno M, MacPherson P, Esmail H. Treatment preferences among people at risk of developing tuberculosis: A discrete choice experiment. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002804. [PMID: 39028696 PMCID: PMC11259259 DOI: 10.1371/journal.pgph.0002804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/01/2024] [Indexed: 07/21/2024]
Abstract
Diagnosing and treating people with bacteriologically-negative but radiologically-apparent tuberculosis (TB) may contribute to more effective TB care and reduce transmission. However, optimal treatment approaches for this group are unknown. It is important to understand peoples' preferences of treatment options for effective programmatic implementation of people-centred treatment approaches. We designed and implemented a discrete choice experiment (DCE) to solicit treatment preferences among adults (≥18 years) with TB symptoms attending a primary health clinic in Blantyre, Malawi. Treatment attributes included in the DCE were as follows: duration of treatment; number of tablets per dose; reduction in the risk of being unwell with TB disease; likelihood of infecting others; adverse effects from the treatment; frequency of follow up; and the annual travel cost to access care. Quantitative choice modelling with multinomial logit models estimated through frequentist and Bayesian approaches investigated preferences for the management of bacteriologically-negative, but radiographically-apparent TB. 128 participants were recruited (57% male, 43.8% HIV-positive, 8.6% previously treated for TB). Participants preferred to take any treatment compared to not taking treatment (odds ratio [OR] 5.78; 95% confidence interval [CI]: 2.40, 13.90). Treatments that reduced the relative risk of developing TB disease by 80% were preferred (OR: 2.97; 95% CI: 2.09, 4.21) compared to treatments that lead to a lower reduction in risk of 50%. However, there was no evidence for treatments that are 95% effective being preferred over those that are 80% effective. Participants strongly favoured the treatments that could completely stop transmission (OR: 7.87, 95% CI: 5.71, 10.84), and prioritised avoiding side effects (OR: 0.19, 95% CI: 0.12, 0.29). There was no evidence of an interaction between perceived TB disease risk and treatment preferences. In summary, participants were primarily concerned with the effectiveness of TB treatments and strongly preferred treatments that removed the risk of onward transmission. Person-centred approaches of preferences for treatment should be considered when designing new treatment strategies. Understanding treatment preferences will ensure that any recommended treatment for probable early TB disease is well accepted and utilized by the public.
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Affiliation(s)
- Wala Kamchedzera
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Matthew Quaife
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Wezi Msukwa-Panje
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Rachael M. Burke
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Liana Macpherson
- MRC Clinical Trials Unit at University College London, London, England, United Kingdom
| | - Moses Kumwenda
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Hussein H. Twabi
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Helse-Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Matteo Quartagno
- MRC Clinical Trials Unit at University College London, London, England, United Kingdom
| | - Peter MacPherson
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
- School of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Hanif Esmail
- MRC Clinical Trials Unit at University College London, London, England, United Kingdom
- WHO Collaborating Centre on Tuberculosis Research and Innovation, Institute for Global Health, University College London, London, United Kingdom
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Asare-Baah M, Salmon-Trejo LAT, Venkatappa T, Garfein RS, Aiona K, Haas M, Séraphin MN. Factors Associated With the Discontinuation of Two Short-Course Tuberculosis Preventive Therapies in Programmatic Settings in the United States. Open Forum Infect Dis 2024; 11:ofae313. [PMID: 38915338 PMCID: PMC11194754 DOI: 10.1093/ofid/ofae313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/03/2024] [Indexed: 06/26/2024] Open
Abstract
Background The objective of this study was to investigate timing and risk factors for discontinuation of short-course tuberculosis preventive therapy (TPT) comparing directly observed 3-month isoniazid/rifapentine (3HP) vs self-administered 4-month rifampin (4R). Methods This was a subanalysis of a 6-month health department cohort (2016-2017) of 993 latent tuberculosis infection (LTBI) patients initiating 3HP (20%) or 4R (80%). Time at risk of TPT discontinuation was compared across regimens. Risk factors were assessed using mixed-effects Cox models. Results Short-course TPT discontinuation was higher with 4R (31% vs 14%; P < .0001), though discontinuation timing was similar. Latino ethnicity (hazard ratio [HR], 1.80; 95% CI, 1.20-2.90) and adverse events (HR, 4.30; 95% CI, 2.60-7.30) increased 3HP discontinuation risk. Social-behavioral factors such as substance misuse (HR, 12.00; 95% CI, 2.20-69.00) and congregate living (HR, 21.00; 95% CI, 1.20-360.00) increased 4R discontinuation risk. Conclusions TPT discontinuation differed by regimen, with distinct risk factors. Addressing social determinants of health within TPT programs is critical to enhance completion rates and reduce TB disease risk in marginalized populations.
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Affiliation(s)
- Michael Asare-Baah
- Department of Epidemiology, University of Florida, Gainsville, Florida, USA
- Emerging Pathogens Institute, University of Florida, Gainsville, Florida, USA
| | - LaTweika A T Salmon-Trejo
- Department of Medicine, Division of Infectious Diseases and Global Medicine, University of Florida, Gainsville, Florida, USA
- Institute of Public Health, Florida A & M University, Tallahassee, Florida, USA
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Thara Venkatappa
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Richard S Garfein
- Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Kaylynn Aiona
- Public Health Institute at Denver Health, Denver, Colorado, USA
| | - Michelle Haas
- Division of Mycobacterial and Respiratory Infections, National Jewish Health, Denver, Colorado, USA
| | - Marie Nancy Séraphin
- Emerging Pathogens Institute, University of Florida, Gainsville, Florida, USA
- Department of Medicine, Division of Infectious Diseases and Global Medicine, University of Florida, Gainsville, Florida, USA
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Semitala FC, Kadota JL, Musinguzi A, Welishe F, Nakitende A, Akello L, Kunihira Tinka L, Nakimuli J, Ritar Kasidi J, Bishop O, Nakasendwa S, Baik Y, Patel D, Sammann A, Nahid P, Belknap R, Kamya MR, Handley MA, Phillips PPJ, Katahoire A, Berger CA, Kiwanuka N, Katamba A, Dowdy DW, Cattamanchi A. Comparison of 3 optimized delivery strategies for completion of isoniazid-rifapentine (3HP) for tuberculosis prevention among people living with HIV in Uganda: A single-center randomized trial. PLoS Med 2024; 21:e1004356. [PMID: 38377166 PMCID: PMC10914279 DOI: 10.1371/journal.pmed.1004356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/05/2024] [Accepted: 02/02/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Expanding access to shorter regimens for tuberculosis (TB) prevention, such as once-weekly isoniazid and rifapentine taken for 3 months (3HP), is critical for reducing global TB burden among people living with HIV (PLHIV). Our coprimary hypotheses were that high levels of acceptance and completion of 3HP could be achieved with delivery strategies optimized to overcome well-contextualized barriers and that 3HP acceptance and completion would be highest when PLHIV were provided an informed choice between delivery strategies. METHODS AND FINDINGS In a pragmatic, single-center, 3-arm, parallel-group randomized trial, PLHIV receiving care at a large urban HIV clinic in Kampala, Uganda, were randomly assigned (1:1:1) to receive 3HP by facilitated directly observed therapy (DOT), facilitated self-administered therapy (SAT), or informed choice between facilitated DOT and facilitated SAT using a shared decision-making aid. We assessed the primary outcome of acceptance and completion (≥11 of 12 doses of 3HP) within 16 weeks of treatment initiation using proportions with exact binomial confidence intervals (CIs). We compared proportions between arms using Fisher's exact test (two-sided α = 0.025). Trial investigators were blinded to primary and secondary outcomes by study arm. Between July 13, 2020, and July 8, 2022, 1,656 PLHIV underwent randomization, with equal numbers allocated to each study arm. One participant was erroneously enrolled a second time and was excluded in the primary intention-to-treat analysis. Among the remaining 1,655 participants, the proportion who accepted and completed 3HP exceeded the prespecified 80% target in the DOT (0.94; 97.5% CI [0.91, 0.96] p < 0.001), SAT (0.92; 97.5% CI [0.89, 0.94] p < 0.001), and Choice (0.93; 97.5% CI [0.91, 0.96] p < 0.001) arms. There was no difference in acceptance and completion between any 2 arms overall or in prespecified subgroup analyses based on sex, age, time on antiretroviral therapy, and history of prior treatment for TB or TB infection. Only 14 (0.8%) participants experienced an adverse event prompting discontinuation of 3HP. The main limitation of the study is that it was conducted in a single center. Multicenter studies are now needed to confirm the feasibility and generalizability of the facilitated 3HP delivery strategies in other settings. CONCLUSIONS Short-course TB preventive treatment was widely accepted by PLHIV in Uganda, and very high levels of treatment completion were achieved in a programmatic setting with delivery strategies tailored to address known barriers. TRIAL REGISTRATION ClinicalTrials.gov NCT03934931.
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Affiliation(s)
- Fred C. Semitala
- Makerere University, Department of Medicine, College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala Uganda
| | - Jillian L. Kadota
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | | | - Fred Welishe
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Anne Nakitende
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Lydia Akello
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Jane Nakimuli
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Opira Bishop
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Suzan Nakasendwa
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Yeonsoo Baik
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Devika Patel
- The Better Lab and Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Amanda Sammann
- The Better Lab and Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Payam Nahid
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Robert Belknap
- Denver Health and Hospital Authority and Division of Infectious Diseases, Department of Medicine, University of Colorado, Denver, Colorado, United States of America
| | - Moses R. Kamya
- Makerere University, Department of Medicine, College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Margaret A. Handley
- Center for Vulnerable Populations, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Patrick PJ Phillips
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Anne Katahoire
- Child Health and Development Center, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Christopher A. Berger
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Achilles Katamba
- Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - David W. Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Adithya Cattamanchi
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, California, United States of America
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Landscape of TB Infection and Prevention among People Living with HIV. Pathogens 2022; 11:pathogens11121552. [PMID: 36558886 PMCID: PMC9786705 DOI: 10.3390/pathogens11121552] [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: 11/05/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Tuberculosis (TB) is one of the leading causes of mortality in people living with HIV (PLHIV) and contributes to up to a third of deaths in this population. The World Health Organization guidelines aim to target early detection and treatment of TB among PLHIV, particularly in high-prevalence and low-resource settings. Prevention plays a key role in the fight against TB among PLHIV. This review explores TB screening tools available for PLHIV, including symptom-based screening, chest radiography, tuberculin skin tests, interferon gamma release assays, and serum biomarkers. We then review TB Preventive Treatment (TPT), shown to reduce the progression to active TB and mortality among PLHIV, and available TPT regimens. Last, we highlight policy-practice gaps and barriers to implementation as well as ongoing research needs to lower the burden of TB and HIV coinfection through preventive activities, innovative diagnostic tests, and cost-effectiveness studies.
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Kazibwe A, Bisaso KR, Kyazze AP, Ninsiima S, Ssekamatte P, Bongomin F, Baluku JB, Kibirige D, Akabwai GP, Kamya MR, Mayanja-Kizza H, Byakika-Kibwika P, Kagimu M, Kalyesubula R, Andia-Biraro I. HIV, tuberculosis, diabetes mellitus and hypertension admissions and premature mortality among adults in Uganda from 2011 to 2019: is the tide turning? Trop Med Health 2022; 50:54. [PMID: 35948991 PMCID: PMC9458845 DOI: 10.1186/s41182-022-00447-y] [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: 07/04/2022] [Accepted: 08/01/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The growing burden of diabetes mellitus (DM) and hypertension (HTN) on the background of endemic Human Immuno-deficiency Virus (HIV) and tuberculosis (TB) is a concern in low- and middle-income countries. We aimed to describe annual trends in admissions, mortality rates and premature mortality (years of potential life lost-YPLLs) due to HIV, tuberculosis (TB), diabetes mellitus (DM) and hypertension (HTN) in Uganda. METHODS We conducted a retrospective cohort study, retrieving electronic records of adults admitted to Mulago and Kiruddu national referral hospitals medical wards between 1st January 2011 and 31st December 2019. We used STATA BE 17.0 and GraphPad Prism 8.0.2 to compute total admissions, inpatient crude mortality rates, and YPLLs; and demonstrate trends using Mann-Kendall test. RESULTS Of 108,357 admissions, 55,620 (51.3%) were female, 15,300 (14.1%) were recorded in 2012, and 22,997 (21.2%) were aged 21-30 years. HIV, TB, DM and HTN accounted for 26,021 (24.0%); 9537 (8.8%); 13,708 (12.7) and 13,252 (12.2%) of all admissions, respectively. Overall inpatient mortality was 16.7% (18,099/108,357), 53.5% (9674/18,099) were male, 21.5% (3898) were aged 31-40 years and 2597 (14.4%) were registered in 2013. HIV, TB, DM and HTN accounted for 35.6% (6444), 14.6% (2646), 9.1% (1648) and 11.8% (2142) of all deaths, respectively. Total admissions (Kendall's tau-B = - 0.833, p < 0.001) and deaths declined (Kendall's tau-B = - 0.611, p = 0.029). A total of 355,514 (mean = 20.8 years, SD 30.0) YPLLs were recorded, of which 54.6% (191,869) were in males; 36.2% (128,755) were among those aged 21-30 years and were recorded in 2012 (54,717; 15.4%). HIV, TB, DM and HTN accounted for 46.5% (165,352); 19.5% (69,347); 4.8% (16,991) and 4.5% (16,167) of YPLLs, respectively. Proportionate contribution of HIV to deaths and YPLLs declined, remained stagnant for TB; and increased for both DM and HTN. CONCLUSION TB and HIV account for higher though declining, while DM and HTN account for lower albeit rising morbidity and premature mortality among adult medical patients in Uganda. TB prevention and treatment; and DM/HTN service integration in HIV care should be optimized and scaled up.
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Affiliation(s)
- Andrew Kazibwe
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, P. O. Box 7072, Kampala, Uganda ,Directorate of Programs, The AIDS Support Organisation, P. O. Box 10443, Kampala, Uganda
| | | | - Andrew Peter Kyazze
- grid.11194.3c0000 0004 0620 0548Tuberculosis and Co-Morbidities (TAC) Research Group, Makerere University, Kampala, Uganda
| | - Sandra Ninsiima
- grid.11194.3c0000 0004 0620 0548Tuberculosis and Co-Morbidities (TAC) Research Group, Makerere University, Kampala, Uganda
| | - Phillip Ssekamatte
- grid.11194.3c0000 0004 0620 0548Tuberculosis and Co-Morbidities (TAC) Research Group, Makerere University, Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, P. O. Box 7072, Kampala, Uganda
| | - Felix Bongomin
- grid.442626.00000 0001 0750 0866Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, P. O. Box 166, Gulu, Uganda
| | - Joseph Baruch Baluku
- grid.513250.0Division of Pulmonology, Kiruddu National Referral Hospital, Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Davis Kibirige
- Uganda Martyrs Hospital, Lubaga, P. O. Box 14130, Kampala, Uganda
| | - George Patrick Akabwai
- grid.423308.e0000 0004 0397 2008Baylor College of Medicine, Children’s Foundation, Kampala, Uganda
| | - Moses R. Kamya
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, P. O. Box 7072, Kampala, Uganda
| | - Harriet Mayanja-Kizza
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, P. O. Box 7072, Kampala, Uganda
| | - Pauline Byakika-Kibwika
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, P. O. Box 7072, Kampala, Uganda
| | - Magid Kagimu
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, P. O. Box 7072, Kampala, Uganda
| | - Robert Kalyesubula
- grid.11194.3c0000 0004 0620 0548Department of Physiology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Irene Andia-Biraro
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, P. O. Box 7072, Kampala, Uganda ,grid.415861.f0000 0004 1790 6116Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
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Mesic A, Ishaq S, Khan WH, Mureed A, Mar HT, Khaing EE, Bermudez-Aza E, Rose L, Lynen L, Seddiq MK, Amirzada HK, Keus K, Decroo T. Person-centred care and short oral treatment for rifampicin-resistant tuberculosis improve retention in care in Kandahar, Afghanistan. Trop Med Int Health 2022; 27:207-215. [PMID: 34978748 PMCID: PMC9306566 DOI: 10.1111/tmi.13716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objectives To describe the effect of adaptations to a person‐centred care with short oral regimens on retention in care for rifampicin‐resistant TB (RR‐TB) in Kandahar province, Afghanistan. Methods The study included people with RR‐TB registered in the programme between 01 October 2016 and 18 April 2021. From 19 November 2019, the programme implemented a trial investigating the safety and effectiveness of short oral RR‐TB regimens. During the trial, person‐centred care was adapted. We included the data from people living with RR‐TB treated in the period before and after the care model was adapted and applied Kaplan‐Meier statistics to compare rates of retention in care. Results Of 236 patients registered in the RR‐TB programme, 146 (61.9%) were registered before and 90 (38.1%) after the model of care was adapted. Before adaptations enhancing person‐centred care, pre‐treatment attrition was 23.3% (n = 34/146), whilst under the adapted care model it was 5.6% (n = 5/90). Attrition on treatment was 22.3% (n = 25/112) before adaptations, whilst during the study period none of the participants were lost‐to‐follow‐up on treatment and 3.3% died (n = 3/90). Conclusions As person‐centred care delivery and treatment regimens were adapted to better fit‐specific contextual challenges and the needs of the target population, retention in care improved amongst people with RR‐TB in Kandahar, Afghanistan.
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Affiliation(s)
- Anita Mesic
- Médecins Sans Frontières, Amsterdam, The Netherlands.,Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | | | | | | | | | | | | | | | - Lutgarde Lynen
- Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | | | - Hashim Khan Amirzada
- National Tuberculosis Control Programme, Ministry of Public Health, Kabul, Afghanistan
| | - Kees Keus
- Médecins Sans Frontières, Amsterdam, The Netherlands
| | - Tom Decroo
- Institute of Tropical Medicine Antwerp, Antwerp, Belgium.,Research Foundation Flanders, Brussels, Belgium
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Semitala FC, Kadota JL, Musinguzi A, Nabunje J, Welishe F, Nakitende A, Akello L, Bishop O, Patel D, Sammann A, Nahid P, Belknap R, Kamya MR, Handley MA, Phillips PPJ, Katahoire A, Berger CA, Kiwanuka N, Katamba A, Dowdy DW, Cattamanchi A. Completion of isoniazid-rifapentine (3HP) for tuberculosis prevention among people living with HIV: Interim analysis of a hybrid type 3 effectiveness-implementation randomized trial. PLoS Med 2021; 18:e1003875. [PMID: 34914696 PMCID: PMC8726462 DOI: 10.1371/journal.pmed.1003875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/04/2022] [Accepted: 11/25/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Scaling up shorter regimens for tuberculosis (TB) prevention such as once weekly isoniazid-rifapentine (3HP) taken for 3 months is a key priority for achieving targets set forth in the World Health Organization's (WHO) END TB Strategy. However, there are few data on 3HP patient acceptance and completion in the context of routine HIV care in sub-Saharan Africa. METHODS AND FINDINGS The 3HP Options Trial is a pragmatic, parallel type 3 effectiveness-implementation randomized trial comparing 3 optimized strategies for delivering 3HP-facilitated directly observed therapy (DOT), facilitated self-administered therapy (SAT), or informed choice between DOT and SAT using a shared decision-making aid-to people receiving care at a large urban HIV clinic in Kampala, Uganda. Participants and healthcare providers were not blinded to arm assignment due to the nature of the 3HP delivery strategies. We conducted an interim analysis of participants who were enrolled and exited the 3HP treatment period between July 13, 2020 and April 30, 2021. The primary outcome, which was aggregated across trial arms for this interim analysis, was the proportion who accepted and completed 3HP (≥11 of 12 doses within 16 weeks of randomization). We used Bayesian inference analysis to estimate the posterior probability that this proportion would exceed 80% under at least 1 of the 3HP delivery strategies, a coprimary hypothesis of the trial. Through April 2021, 684 participants have been enrolled, and 479 (70%) have exited the treatment period. Of these 479 participants, 309 (65%) were women, mean age was 41.9 years (standard deviation (SD): 9.2), and mean time on antiretroviral therapy (ART) was 7.8 years (SD: 4.3). In total, 445 of them (92.9%, 95% confidence interval (CI): [90.2 to 94.9]) accepted and completed 3HP treatment. There were no differences in treatment acceptance and completion by sex, age, or time on ART. Treatment was discontinued due to a documented adverse event (AE) in 8 (1.7%) patients. The probability that treatment acceptance and completion exceeds 80% under at least 1 of the three 3HP delivery strategies was greater than 99%. The main limitations are that the trial was conducted at a single site, and the interim analysis focused on aggregate outcome data to maintain blinding of investigators to arm-specific outcomes. CONCLUSIONS 3HP was widely accepted by people living with HIV (PLHIV) in Uganda, and very high levels of treatment completion were achieved in a programmatic setting. These findings show that 3HP can enable effective scale-up of tuberculosis preventive therapy (TPT) in high-burden countries, particularly when delivery strategies are tailored to target known barriers to treatment completion. TRIAL REGISTRATION ClinicalTrials.gov NCT03934931.
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Affiliation(s)
- Fred C. Semitala
- Makerere University, Department of Medicine, College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Jillian L. Kadota
- UCSF Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Juliet Nabunje
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Fred Welishe
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Anne Nakitende
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Lydia Akello
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Opira Bishop
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Devika Patel
- The Better Lab, Department of Surgery, University of California, San Francisco, San Francisco, California, United States of America
| | - Amanda Sammann
- The Better Lab, Department of Surgery, University of California, San Francisco, San Francisco, California, United States of America
| | - Payam Nahid
- UCSF Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
| | - Robert Belknap
- Denver Health and Hospital Authority and Division of Infectious Diseases, Department of Medicine, University of Colorado, Denver, Colorado, United States of America
| | - Moses R. Kamya
- Makerere University, Department of Medicine, College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Margaret A. Handley
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Patrick P. J. Phillips
- UCSF Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
| | - Anne Katahoire
- Child Health and Development Center, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Christopher A. Berger
- UCSF Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
| | - Noah Kiwanuka
- Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Achilles Katamba
- Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - David W. Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Adithya Cattamanchi
- UCSF Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- * E-mail:
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8
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Lim RK, Talavlikar R, Chiazor O, Bietz J, Gardiner H, Fisher D. Fewer losses in the cascade of care for latent tuberculosis with solo interferon-gamma release assay screening compared to sequential screening. BMC Infect Dis 2021; 21:936. [PMID: 34503458 PMCID: PMC8431896 DOI: 10.1186/s12879-021-06637-z] [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: 03/11/2021] [Accepted: 08/12/2021] [Indexed: 11/26/2022] Open
Abstract
Background Refugees are at increased risk of developing tuberculosis (TB) soon after resettlement. Targeting high-risk populations for latent tuberculosis infection (LTBI) screening and treatment is an important measure towards eliminating TB in low incidence countries, however, there are low rates of screening and treatment completion in the LTBI cascade of care. The authors hypothesized that an interferon-gamma release assay (IGRA) screening strategy would lead to a higher proportion of refugees completing LTBI screening and treatment, compared to sequential screening with tuberculin skin test (TST) and confirmatory IGRA. Methods This retrospective cohort study included eligible refugees screened with a sequential strategy versus a solo-IGRA strategy at different time periods from a centralized refugee clinic. The primary outcome was the proportion completing LTBI screening in each cohort. Results A total of 471 subjects were included (240 in sequential screening, 231 in solo-IGRA screening). 54% of refugees completed LTBI screening with sequential testing, compared to 85% of those screened with a solo-IGRA. Time to completing screening was also shorter in the solo-QFT group (difference 16.5 days, p < 0.01, 95% confidence interval 9.3, 23.7). There was a higher incidence of LTBI diagnosis in the solo-IGRA group (41 versus 20, p = 0.002). Screening completion was predicted by solo-IGRA screening (aOR 3.74, 95% confidence interval 2.30, 6.09; p < 0.001) and if refugees were privately-sponsored (aOR 2.81, 95% confidence interval 1.53, 5.15; p = 0.001). Treatment completion rates did not differ between groups. Conclusion This study has identified fewer dropouts in the LTBI cascade of care if a solo-IGRA strategy is used for screening. An IGRA should be strongly considered as the screening method for refugees arriving in low-incidence settings if resources are available.
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Affiliation(s)
- R K Lim
- Cumming School of Medicine, University of Calgary, Alberta, Canada.
| | - R Talavlikar
- Mosaic Refugee Health Clinic, Mosaic Primary Care Network, Calgary, AB, Canada
| | - O Chiazor
- Mosaic Refugee Health Clinic, Mosaic Primary Care Network, Calgary, AB, Canada
| | - J Bietz
- Mosaic Refugee Health Clinic, Mosaic Primary Care Network, Calgary, AB, Canada
| | - H Gardiner
- Calgary Tuberculosis Services, Alberta Health Services, Calgary, AB, Canada
| | - D Fisher
- Cumming School of Medicine, University of Calgary, Alberta, Canada
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Semitala FC, Musinguzi A, Ssemata J, Welishe F, Nabunje J, Kadota JL, Berger CA, Katamba A, Kiwanuka N, Kamya MR, Dowdy D, Cattamanchi A, Katahoire AR. Acceptance and completion of rifapentine-based TB preventive therapy (3HP) among people living with HIV (PLHIV) in Kampala, Uganda-patient and health worker perspectives. Implement Sci Commun 2021; 2:71. [PMID: 34193311 PMCID: PMC8247167 DOI: 10.1186/s43058-021-00173-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 06/09/2021] [Indexed: 11/25/2022] Open
Abstract
Background A 12-dose, once-weekly regimen of isoniazid and rifapentine (3HP) is effective in preventing tuberculosis (TB) among people living with HIV (PLHIV). We sought to identify potential barriers to and facilitators of acceptance and completion of 3HP treatment from the perspective of people living with HIV (PLHIV) and health workers in a routine HIV care setting in Kampala, Uganda. Methods We conducted semi-structured interviews with 25 PLHIV and 10 health workers at an HIV/AIDS clinic in Kampala, Uganda. For both groups, we explored their understanding and interpretations of TB and TB preventive therapy (TPT), and perceptions about social and contextual factors that might influence the willingness of PLHIV to initiate and complete 3HP. We analyzed the data using an inductive thematic approach and aligned the emergent themes to the Behavior Change Wheel framework to identify sources of behavior and targeted behavior change interventions. Results Facilitators of acceptance and completion of 3HP treatment among PLHIV were fear of contracting TB, awareness of being at risk of getting TB, willingness to take TPT, trust in health workers, and the perceived benefits of directly observed therapy (DOT) and self-administered therapy (SAT) 3HP delivery strategies. Barriers included inadequate understanding of TPT, fear of potential side effects, concerns about the effectiveness of 3HP, and the perceived challenges of DOT or SAT. Among health workers, perceived facilitators included knowledge that TB is a common cause of mortality for PLHIV, fear of getting TB, and trust in the health workers by PLHIV, the advantages of once-weekly 3HP dosing, and the benefits of DOT and SAT 3HP delivery strategies. Health worker-reported barriers for PLHIV included inadequate understanding of TB and benefits of TPT, TB-associated stigma, potential side effects pill burden, and challenges of DOT and SAT 3HP delivery strategies. Lack of experience in the use of digital technology to monitor patient care was identified as a health worker-specific barrier. Identified intervention functions to address the facilitators or barriers included education, persuasion, environmental restructuring, enablement, and training. Conclusions Using a formative qualitative and comprehensive theoretical approach, we identified key barriers, facilitators, and appropriate interventions, including patient education, enhancing trust, and patient-centered treatment support that could be used to optimize the delivery of 3HP to PLHIV in our setting. These interventions are likely generalizable to other clinical interventions in similar populations in sub-Saharan Africa and other TB high-burden settings. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00173-2.
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Affiliation(s)
- Fred C Semitala
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda. .,Makerere University Joint AIDS Program (MJAP), Kampala, Uganda. .,Infectious Diseases Research Collaboration, Kampala, Uganda.
| | | | - Jackie Ssemata
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Fred Welishe
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Juliet Nabunje
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jillian L Kadota
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Christopher A Berger
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Achilles Katamba
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Noah Kiwanuka
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moses R Kamya
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - David Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA.,Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda.,Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Anne R Katahoire
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
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