Travel distance to rifampicin-resistant tuberculosis treatment and its impact on loss to follow-up: the importance of continued RR-TB treatment decentralization in South Africa

BACKGROUND

Understanding why patients experience loss to follow-up (LTFU) is essential for TB control. This analysis examines the impact of travel distance to RR-TB treatment on LTFU, which has yet to be analyzed within South Africa.

METHODS

We retrospectively analyzed 1436 patients treated for RR-TB at ten South African public hospitals. We linked patients to their residential ward using data reported to NHLS and maps available from the Municipal Demarcation Board. Travel distance was calculated from each patient's ward centroid to their RR-TB treatment site using the georoute command in Stata. The relationship between LTFU and travel distance was modeled using multivariable logistic regression.

RESULTS

Among 1436 participants, 75.6% successfully completed treatment and 24.4% were LTFU. The median travel distance was 40.96 km (IQR: 17.12, 63.49). A travel distance > 60 km increased odds of LTFU by 91% (p = 0.001) when adjusting for HIV status, age, sex, education level, employment status, residential locale, treatment regimen, and treatment site.

CONCLUSION

People living in KwaZulu-Natal and Eastern Cape travel long distances to receive RR-TB care, placing them at increased risk for LTFU. Policies that bring RR-TB treatment closer to patients, such as further decentralization to PHCs, are necessary to improve RR-TB outcomes.

Exploring HIV disease indicators at MDR-TB treatment initiation in South Africa

BACKGROUND: Understanding relationships between HIV and multidrug-resistant TB (MDR-TB) is crucial for ensuring successful MDR-TB outcomes.METHODS: We used a cross-sectional analysis to evaluate sociodemographic and clinical characteristics as correlates of antiretroviral therapy (ART) use, having an HIV viral load (VL) result, and HIV viral suppression in a cross-sectional sample of people with HIV (PWH) and MDR-TB enrolled in a cluster-randomized trial of nurse case management to improve MDR-TB outcomes.RESULTS: Among 1,479 PWH, the mean age was 37.1 years; 809 (54.7%) were male, and 881 (59.6%) were taking ART. Housing location, employment status, and CD4 count differed significantly between those taking vs. those not taking ART. Among the 881 taking ART, 681 (77.3%) had available HIV VL results. Housing location, CD4 count, and prior history of TB differed significantly between those with and without a VL result. Among the 681 with a VL result, 418 (61.4%) were virally suppressed. Age, education level, CD4 count, TB history, housing location, and ART type differed significantly between those with and without viral suppression.CONCLUSION: PWH presenting for MDR-TB treatment with a history of TB, taking a protease inhibitor, or living in a township may risk poor MDR-TB outcomes.

"It was almost like it's set up for people to fail" A qualitative analysis of experiences and unmet supportive needs of people with Long COVID

BACKGROUND

Almost twenty percent of adults with COVID-19 develop Long COVID, leading to prolonged symptoms and disability. Understanding the supportive needs of people with Long COVID is vital to enacting effective models of care and policies.

DESIGN/METHODS

This qualitative sub-study explored the experiences of people with Long COVID and their unmet needs. Participants enrolled in a larger study to evaluate the post-acute cardiovascular impacts of COVID-19 were invited to participate in subsequent in-depth interviews. Participants were enrolled purposively until saturation at 24 participants. Data were analyzed using thematic content analysis.

RESULTS

Participants focused on adaptations to life with Long COVID and their unmet needs in different life spheres. Three domains, 1) occupational and financial; 2) healthcare-related; and 3) social and emotional support, emerged as areas affecting quality of life. Although participants were motivated to return to work for financial and personal reasons, Long COVID symptoms often resulted in the inability to perform tasks required by their existing jobs, and unemployment. Those who maintained employment through employer accommodations still needed additional support. Participants encountered diagnostic challenges, challenges in accessing specialty appointments, insurance loopholes, high healthcare costs, and medical skepticism. Existing social networks provided support for completing daily tasks; however, those with Long COVID typically turned to others with similar lived experiences for emotional support. Participants found government support programs inadequate and difficult to access in all three domains.

DISCUSSION

We propose a five-pronged policy approach to support persons with Long COVID. These overarching recommendations are (1) improve public awareness of Long COVID; (2) improve clinical care quality and access; (3) implement additional school and workplace accommodations; (4) strengthen socioeconomic benefits and social services; and (5) improve research on Long COVID.

Identity management in the face of HIV and intersecting stigmas: A metasynthesis of qualitative reports from sub-Saharan Africa

While stigma experienced by people living with HIV (PLWH) is well documented, intersectional stigma and additional stigmatized identities have not received similar attention. The purpose of this metasynthesis is to identify salient stigmatized intersections and their impact on health outcomes in PLWH in sub-Saharan Africa. Using Sandelowski and Barroso's metasynthesis method, we searched four databases for peer-reviewed qualitative literature. Included studies (1) explored personal experiences with intersecting stigmas, (2) included ≥1 element of infectious disease stigma, and (3) were conducted in sub-Saharan Africa. Our multinational team extracted, aggregated, interpreted, and synthesized the findings. From 454 screened abstracts, the 34 studies included in this metasynthesis reported perspectives of at least 1258 participants (282 men, 557 women, and 109 unspecified gender) and key informants. From these studies, gender and HIV was the most salient stigmatized intersection, with HIV testing avoidance and HIV-status denial seemingly more common among men to preserve traditional masculine identity. HIV did not threaten female identity in the same way with women more willing to test for HIV, but at the risk of abandonment and withdrawal of financial support. To guard against status loss, men and women used performative behaviors to highlight positive qualities or minimize perceived negative attributes. These identity management practices ultimately shaped health behaviors and outcomes. From this metasynthesis, the Stigma Identity Framework was devised for framing identity and stigma management, focusing on role expectation and fulfillment. This framework illustrates how PLWH create, minimize, or emphasize other identity traits to safeguard against status loss and discrimination. Providers must acknowledge how stigmatization disrupts PLWH's ability to fit into social schemas and tailor care to individuals' unique intersecting identities. Economic security and safety should be considered in women's HIV care, while highlighting antiretrovirals' role in preserving strength and virility may improve care engagement among men.

Context Matters: A Qualitative Synthesis of Adherence Literature for People on Hemodialysis

BACKGROUND

Patients with ESKD treated with hemodialysis in the United States have persistently higher rates of nonadherence compared with patients in other developed countries. Nonadherence is associated with an increased risk of death and higher medical expenditure. There is an urgent need to address it with feasible, effective interventions as the prevalence of patients on hemodialysis in the United States continues to grow. However, published adherence interventions demonstrate limited long-term efficacy.

METHODS

We conducted a synthesis of qualitative studies on adherence to hemodialysis treatment, medications, and fluid and dietary restrictions to identify gaps in published adherence interventions, searching PubMed, CINAHL, PsychInfo, Embase, and Web of Science databases. We analyzed qualitative data with a priori codes derived from the World Health Organization's adherence framework and subsequent codes from thematic analysis.

RESULTS

We screened 1775 articles and extracted qualitative data from 12. The qualitative data revealed 20 factors unique to hemodialysis across the World Health Organization's five dimensions of adherence. In addition, two overarching themes emerged from the data: (1) adherence in the context of patients' whole lives and (2) dialysis treatment as a double-edged sword. Patient-level factors reflected in the qualitative data extended beyond knowledge about hemodialysis treatment or motivation to adhere to treatment. Patients described a profound grieving process over the loss of their "old self" that impacted adherence. They also navigated complex challenges that could be exacerbated by social determinants of health as they balanced treatment, life tasks, and social roles.

CONCLUSIONS

This review adds to the growing evidence that one-size-fits-all approaches to improving adherence among patients on hemodialysis are inadequate. Adherence may improve when routine care incorporates patient context and provides ongoing support to patients and families as they navigate the logistical, physical, and psychological hardships of living with dialysis. New research is urgently needed to guide a change in course.

Monkeypox Virus Outbreak 2022: Key Epidemiologic, Clinical, Diagnostic, and Prevention Considerations

ABSTRACT

Monkeypox is a zoonotic infection that manifests as dermatologic lesions that may be painful or pruritic and can appear on the face, trunk, extremities, genitals, and mucosal surfaces. In 2022, cases of monkeypox increased exponentially and it was declared a public health emergency by the World Health Organization and the U.S. Department of Health and Human Services. Unlike previous monkeypox outbreaks, the current situation has disproportionately affected men who have sex with men and seems to be associated with lower mortality. Options for treatment and prevention are limited. The distribution and availability of vaccines and antivirals has posed challenges for patients, clinicians, and public health systems. Early recognition and management of persons with monkeypox is critical in controlling the spread of this infection. This article reviews key features of monkeypox and highlights current recommendations for clinical management, prevention, and considerations for persons with HIV. Implications for public health and nursing are discussed.

Examining family planning and adverse pregnancy outcomes for women with active tuberculosis disease: a systematic review

OBJECTIVES

(1) Summarise and evaluate the current evidence of tuberculosis (TB)-associated pregnancy outcomes, (2) evaluate the state of the science of family planning during TB treatment and (3) provide recommendations to move forward to improve care and outcomes during TB disease.

DESIGN

Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

DATA SOURCES

PubMed, Embase, CINAHL, Cochrane, Web of Science and Scopus were searched from September 2009 to November 2021.

ELIGIBILITY CRITERIA

Studies were included if they assessed pregnant women with active TB, drug-resistant TB (DR-TB) or TB/HIV coinfection and examined pregnancy, maternal, fetal/birth and TB or TB/HIV coinfection outcomes. Studies were also included if they examined family planning services among women initiating TB treatment.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data using PRISMA guidelines and conducted quality assessment using the Joanna-Briggs Institute Critical Appraisal Tools. The level of evidence was reported using the Johns Hopkins Evidence-Based Practice guidelines.

RESULTS

69 studies were included in this review. Case reports, case series, case controls, cohort studies, secondary data analyses and a service delivery improvement project conducted in 26 countries made up the totality of the evidence. Most studies reported pregnancy complications for mothers (anaemia, postpartum haemorrhage, deaths) and fetuses or newborns (low birth weight, premature birth, and spontaneous or induced abortions). Few studies discussed the value of offering family planning to prevent adverse pregnancy outcomes. One study examined the effect of a provider training on contraceptive use with reported increased contraceptive use.

CONCLUSIONS

Integrating family planning services within a TB treatment programme is essential to reduce adverse TB-associated maternal-child outcomes. Despite well-established adverse pregnancy outcomes, little attention has been paid to family planning to prevent poor pregnancy outcomes for women with TB/DR-TB. Recommendations for clinicians, TB programmes and researchers are provided and reflect evidence presented in this review.

Risk factors for poor engagement in drug-resistant TB care in South Africa: a systematic review

BACKGROUND

Metrics of poor patient engagement, including missed appointments, treatment interruption, sub-optimal medication adherence, and loss to follow-up, have been linked to poor clinical multidrug-resistant TB (MDR-TB) outcomes. Understanding the risk factors for poor patient engagement is necessary to improve outcomes and control TB. This review synthesizes the risk factors for poor patient engagement in MDR-TB treatment across South Africa.

DESIGN

A systematic review of five databases (PubMed, Embase, CINAHL, Cochrane, and Web of Science) was conducted, covering articles published between 2010 and 2020. Articles were included if they provided information about risk factors associated with poor engagement among adults (⩾15 years) in treatment for MDR-TB in South Africa. Reviews, editorials, abstracts, and case studies were excluded.

RESULTS

Six studies met the inclusion criteria. Male sex and younger age were the most consistently identified risk factors for poor engagement; however, there was a lack of consistency in the choice of covariates, measurement of the variables, analytic methods, and significant factors associated with poor engagement between studies. Alcohol use, substance use, living with HIV, pulmonary TB site, and ethnicity were all identified as risk factors in at least one included study, while formal housing and steady employment were found to be protective.

CONCLUSION

The available literature offers little cohesive data to address poor patient engagement in this population. Further research needs to focus on identifying and addressing risk factors for poor patient engagement. This is particularly salient within the context of newer all-oral and short-course MDR-TB treatment regimens.