Journal Article > ResearchFull Text
BMC Health Serv Res. 2021 December 6; Volume 21 (Issue 1); 1314.; DOI:10.1186/s12913-021-07323-1
Schausberger B, Mmema N, Dlamini V, Dube L, Aung A, et al.
BMC Health Serv Res. 2021 December 6; Volume 21 (Issue 1); 1314.; DOI:10.1186/s12913-021-07323-1
BACKGROUND
Traditional healing plays an important role in healthcare in Eswatini, and innovative collaborations with traditional healers may enable hard-to-reach men to access HIV and tuberculosis diagnostic services. This study explored attitudes towards integration of traditional healers into the provision of HIV self-testing kits and sputum collection containers.
METHODS
A qualitative study was conducted in 2019-2020 in Shiselweni region, Eswatini. Eight male traditional healers were trained on HIV and tuberculosis care including distribution of HIV self-testing kits and sputum collection containers. Attitudes towards the intervention were elicited through in-depth interviews with the eight traditional healers, ten clients, five healthcare workers and seven focus group discussions with community members. Interviews and group discussions were conducted in SiSwati, audio-recorded, translated and transcribed into English. Data were coded inductively and analysed thematically.
RESULTS
81 HIV self-testing kits and 24 sputum collection containers were distributed by the healers to 99 clients, with 14% of participants reporting a reactive HIV self-test result. The distribution of sputum containers did not result in any tuberculosis diagnoses, as samples were refused at health centres. Traditional healers perceived themselves as important healthcare providers, and after training, were willing and able to distribute HIV self-test kits and sputum containers to clients. Many saw themselves as peers who could address barriers to health-seeking among Swazi men that reflected hegemonic masculinities and patriarchal attitudes. Traditional healers were considered to provide services that were private, flexible, efficient and non-judgemental, although some clients and community members expressed concerns over confidentiality breaches. Attitudes among health workers were mixed, with some calling for greater collaboration with traditional healers and others expressing doubts about their potential role in promoting HIV and tuberculosis services. Specifically, many health workers did not accept sputum samples collected outside health facilities.
CONCLUSIONS
Offering HIV self-testing kits and sputum containers through traditional healers led to high HIV yields, but no TB diagnoses. The intervention was appreciated by healers' clients, due to the cultural literacy of traditional healers and practical considerations. Scaling-up this approach could bridge testing gaps if traditional healers are supported, but procedures for receiving sputum samples at health facilities need further strengthening.
Traditional healing plays an important role in healthcare in Eswatini, and innovative collaborations with traditional healers may enable hard-to-reach men to access HIV and tuberculosis diagnostic services. This study explored attitudes towards integration of traditional healers into the provision of HIV self-testing kits and sputum collection containers.
METHODS
A qualitative study was conducted in 2019-2020 in Shiselweni region, Eswatini. Eight male traditional healers were trained on HIV and tuberculosis care including distribution of HIV self-testing kits and sputum collection containers. Attitudes towards the intervention were elicited through in-depth interviews with the eight traditional healers, ten clients, five healthcare workers and seven focus group discussions with community members. Interviews and group discussions were conducted in SiSwati, audio-recorded, translated and transcribed into English. Data were coded inductively and analysed thematically.
RESULTS
81 HIV self-testing kits and 24 sputum collection containers were distributed by the healers to 99 clients, with 14% of participants reporting a reactive HIV self-test result. The distribution of sputum containers did not result in any tuberculosis diagnoses, as samples were refused at health centres. Traditional healers perceived themselves as important healthcare providers, and after training, were willing and able to distribute HIV self-test kits and sputum containers to clients. Many saw themselves as peers who could address barriers to health-seeking among Swazi men that reflected hegemonic masculinities and patriarchal attitudes. Traditional healers were considered to provide services that were private, flexible, efficient and non-judgemental, although some clients and community members expressed concerns over confidentiality breaches. Attitudes among health workers were mixed, with some calling for greater collaboration with traditional healers and others expressing doubts about their potential role in promoting HIV and tuberculosis services. Specifically, many health workers did not accept sputum samples collected outside health facilities.
CONCLUSIONS
Offering HIV self-testing kits and sputum containers through traditional healers led to high HIV yields, but no TB diagnoses. The intervention was appreciated by healers' clients, due to the cultural literacy of traditional healers and practical considerations. Scaling-up this approach could bridge testing gaps if traditional healers are supported, but procedures for receiving sputum samples at health facilities need further strengthening.
Journal Article > LetterFull Text
Int J Tuberc Lung Dis. 2022 August 1; Volume 26 (Issue 8); 792-794.; DOI:10.5588/ijtld.22.0168
Rekart ML, Morshed T, Mulanda WK, Klieascikova J, Sitali N, et al.
Int J Tuberc Lung Dis. 2022 August 1; Volume 26 (Issue 8); 792-794.; DOI:10.5588/ijtld.22.0168
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2023 October 1; Volume 27 (Issue 10); 748-753.; DOI:10.5588/ijtld.23.0066
Rekart ML, Aung A, Cullip T, Mulanda WK, Mun L, et al.
Int J Tuberc Lung Dis. 2023 October 1; Volume 27 (Issue 10); 748-753.; DOI:10.5588/ijtld.23.0066
BACKGROUND
Tajikistan has a high burden of rifampicin-resistant TB (RR-TB), with 2,700 new cases estimated for 2021 (28/100,000 population). TB is spread among household members through close interaction and children exposed through household contact progress to disease rapidly and frequently.
METHODS
We retrospectively analysed programmatic data from household contact tracing in Dushanbe over 50 months. We calculated person-years of follow-up, contact tracing yield, number needed to screen (NNS) and number needed to test (NNT) to find one new case, and time to diagnosis.
RESULTS
We screened 6,654 household contacts of 830 RR-TB index cases; 47 new RR-TB cases were detected, 43 in Year 1 and 4 in Years 2 or 3. Ten were aged <5 years; 46/47 had TB symptoms, 34/45 had chest radiographs consistent with TB, 11/35 were Xpert Ultra-positive, 29/32 were tuberculin skin test-positive and 28/47 had positive TB culture and phenotypic drug susceptibility results. The NNS to find one RR-TB case was 141.57 and the NNT was 34.49. The yields for different types of contacts were as follows: 0.7% for screened contacts, 2.9% for tested contacts, 17.0% for symptomatic contacts and 12.1% for symptomatic contacts aged below 5 years.
CONCLUSION
RR-TB household contact tracing was feasible and productive in Tajikistan, a low middle-income country with an inefficient healthcare delivery system.
Tajikistan has a high burden of rifampicin-resistant TB (RR-TB), with 2,700 new cases estimated for 2021 (28/100,000 population). TB is spread among household members through close interaction and children exposed through household contact progress to disease rapidly and frequently.
METHODS
We retrospectively analysed programmatic data from household contact tracing in Dushanbe over 50 months. We calculated person-years of follow-up, contact tracing yield, number needed to screen (NNS) and number needed to test (NNT) to find one new case, and time to diagnosis.
RESULTS
We screened 6,654 household contacts of 830 RR-TB index cases; 47 new RR-TB cases were detected, 43 in Year 1 and 4 in Years 2 or 3. Ten were aged <5 years; 46/47 had TB symptoms, 34/45 had chest radiographs consistent with TB, 11/35 were Xpert Ultra-positive, 29/32 were tuberculin skin test-positive and 28/47 had positive TB culture and phenotypic drug susceptibility results. The NNS to find one RR-TB case was 141.57 and the NNT was 34.49. The yields for different types of contacts were as follows: 0.7% for screened contacts, 2.9% for tested contacts, 17.0% for symptomatic contacts and 12.1% for symptomatic contacts aged below 5 years.
CONCLUSION
RR-TB household contact tracing was feasible and productive in Tajikistan, a low middle-income country with an inefficient healthcare delivery system.
Conference Material > Poster
Mun L, Gomez D, Sitali N, Rajabzoda A, Azamova S, et al.
MSF Scientific Days International 2022. 2022 May 9; DOI:10.57740/x1vy-hx80
Conference Material > Abstract
Kerschberger B, Ntshalintshali N, Maphalala G, Aung A, Mamba C, et al.
MSF Scientific Days International 2021: Research. 2021 May 19
INTRODUCTION
Acute HIV infection (AHI) is rarely diagnosed in resource-limited settings. Barriers to diagnosis include the high costs of viral load (VL)-based diagnostic testing algorithms and lack of
availability of reliable point-of-care (POC) tests. We assessed the performance of a new POC test for the detection of AHI in Eswatini, Alere™ HIV-Combo.
METHODS
Adult outpatients testing HIV-negative on Alere™ Determine through finger-prick testing by lay counselors, or with discordant result (Alere™ Determine-positive and Uni-Gold™-negative)
were enrolled at the Nhlangano Health Centre, between March 2019 and March 2020. Participants were then tested with the quantitative Xpert HIV-1 VL assay, used as the gold standard
test for AHI. AHI was defined as a VL result ≥40 copies/mL. Leftover paired venous whole blood and plasma specimens were tested with the lateral flow fourth-generation antibody/p24 POC Alere™ HIV-Combo. Both Xpert and HIV-Combo tests were performed in the laboratory by a laboratory technician. A positive result for AHI using the HIV-Combo test was defined as reactivity on the p24 antigen and/or antibody bars. Diagnostic test characteristics were evaluated for plasma (HIV-Comboplasma) and whole blood (HIV-Combo-wb), as compared with the results of Xpert testing.
ETHICS
This study was approved by the MSF Ethics Review Board and the Eswatini Ethics Committee.
RESULTS
A total of 745 (HIV-Combo-plasma/Xpert) and 429 (HIV-Combowb/ Xpert) paired test results were available. 29/745 (3.9%) and 19/429 (4.4%) were AHI-positive based on the results of Xpert testing. 26/745 (3.5%) were reactive on HIV-Combo-plasma and 16 (3.7%) on HIV-Combo-wb. Most positive test results with HIV-Combo showed reactivity to antibodies only (76.9% HIV-Combo-plasma; 75.0% HIV-Combo-wb), and the remainder to p24 antigen (15.4%, 18.8%) only, or both p24 antigen and antibodies (7.7%, 6.3%). The area under the receiver operating characteristic curve was 0.93 for HIV-Combo-plasma and 0.89 for HIV-Combo-wb. Test sensitivity tended to be slightly higher for HIV-Combo-plasma (86.2%) as compared to HIV-Combo-wb (78.9%), and specificity was high for both tests (≥99.8%). The negative predictive value was above 99.0% for both tests, and positive predictive values were 93.8% for HIV-Combo-wb and 96.2% for HIV-Combo-plasma.
CONCLUSION
Lateral flow POC HIV-Combo testing in this setting was able to diagnose most cases of AHI, in comparison to the gold standard. This test therefore has potential for use in routine settings due to low cost and ease of use. However, further studies are needed to evaluate its performance when used in routine outpatient care settings by lay counselors on finger-prick samples.
CONFLICTS OF INTEREST
None declared.
Acute HIV infection (AHI) is rarely diagnosed in resource-limited settings. Barriers to diagnosis include the high costs of viral load (VL)-based diagnostic testing algorithms and lack of
availability of reliable point-of-care (POC) tests. We assessed the performance of a new POC test for the detection of AHI in Eswatini, Alere™ HIV-Combo.
METHODS
Adult outpatients testing HIV-negative on Alere™ Determine through finger-prick testing by lay counselors, or with discordant result (Alere™ Determine-positive and Uni-Gold™-negative)
were enrolled at the Nhlangano Health Centre, between March 2019 and March 2020. Participants were then tested with the quantitative Xpert HIV-1 VL assay, used as the gold standard
test for AHI. AHI was defined as a VL result ≥40 copies/mL. Leftover paired venous whole blood and plasma specimens were tested with the lateral flow fourth-generation antibody/p24 POC Alere™ HIV-Combo. Both Xpert and HIV-Combo tests were performed in the laboratory by a laboratory technician. A positive result for AHI using the HIV-Combo test was defined as reactivity on the p24 antigen and/or antibody bars. Diagnostic test characteristics were evaluated for plasma (HIV-Comboplasma) and whole blood (HIV-Combo-wb), as compared with the results of Xpert testing.
ETHICS
This study was approved by the MSF Ethics Review Board and the Eswatini Ethics Committee.
RESULTS
A total of 745 (HIV-Combo-plasma/Xpert) and 429 (HIV-Combowb/ Xpert) paired test results were available. 29/745 (3.9%) and 19/429 (4.4%) were AHI-positive based on the results of Xpert testing. 26/745 (3.5%) were reactive on HIV-Combo-plasma and 16 (3.7%) on HIV-Combo-wb. Most positive test results with HIV-Combo showed reactivity to antibodies only (76.9% HIV-Combo-plasma; 75.0% HIV-Combo-wb), and the remainder to p24 antigen (15.4%, 18.8%) only, or both p24 antigen and antibodies (7.7%, 6.3%). The area under the receiver operating characteristic curve was 0.93 for HIV-Combo-plasma and 0.89 for HIV-Combo-wb. Test sensitivity tended to be slightly higher for HIV-Combo-plasma (86.2%) as compared to HIV-Combo-wb (78.9%), and specificity was high for both tests (≥99.8%). The negative predictive value was above 99.0% for both tests, and positive predictive values were 93.8% for HIV-Combo-wb and 96.2% for HIV-Combo-plasma.
CONCLUSION
Lateral flow POC HIV-Combo testing in this setting was able to diagnose most cases of AHI, in comparison to the gold standard. This test therefore has potential for use in routine settings due to low cost and ease of use. However, further studies are needed to evaluate its performance when used in routine outpatient care settings by lay counselors on finger-prick samples.
CONFLICTS OF INTEREST
None declared.
Conference Material > Abstract
Aung A, Mamba C, Ntshalintshali N, Mpala Q, Mthethwa-Hleza S, et al.
MSF Scientific Days International 2020: Research. 2020 May 26
INTRODUCTION
Acute HIV infection (AHI) cannot be detected with routine point-of-care antibody tests and is rarely diagnosed in resource-limited settings. However, characteristics of AHI, including its non-specific clinical presentation accompanied by high levels of plasma viraemia, may contribute to uncontrolled onward transmission within high-prevalence settings. Improving early detection of AHI in such settings could conceivably contribute to reducing onward transmission and thus impact on HIV elimination goals. We aimed to assess the programmatic feasibility of identifying and treating AHI patients in Eswatini, which has already achieved 90-90-90 targets.
METHODS
From March to December 2019, adults aged 16-49 years and attending outpatient departments at Nhlangano Health Center were screened for symptoms suggestive of AHI, including fever, sore throat, and current symptoms of a sexually transmitted infection. Individuals were enrolled into the study on testing negative or inconclusive for HIV using serial rapid diagnostic tests (RDT) Alere Determine™ HIV-1/2 (Abbott, USA) and Uni-Gold™ HIV (Trinity Biotech, Ireland), and on referral from HIV pre- and post-exposure prophylaxis programmes, if AHI was suspected. AHI was diagnosed using the Xpert platform (Cepheid, Sunnyvale, USA) to perform quantitative HIV RNA detection. Patients with AHI were offered immediate initiation of antiretroviral therapy (ART), follow-up care, and assisted partner notification.
ETHICS
This study was approved by the National Health Research and Review Board, Eswatini, and the MSF Ethics Review Board.
RESULTS
Of 2177 patients initially screened, 997 (46%) had symptoms suggestive of AHI. Of those, 611 (61%) patients were enrolled and tested with Xpert to assay HIV RNA viral load; this included n=586 because their HIV RDT test was negative; n=12 because HIV RDT was inconclusive; and seven and six were presumptive AHI cases identified in the pre- and post-exposure prophylaxis programmes respectively. Of those enrolled, 26 (4.3%) had a detectable HIV viral load. Median viral load was 4.70 log10 (interquartile range (IQR), 3.70-5.96). The most common complaints of those with AHI were fever, sore throat, headache, genital discharge and lower abdominal pain. 16 (62%) patients initiated ART. After two weeks, eight of 11 patients who were followed up had a suppressed viral load below 1000 copies/ml, and by three months, all patients who were on treatment achieved virological suppression. CD4 count was scheduled at every visit and among those with available test results, the median CD4 count was 476 cells/mm3 (IQR 305-768, n=16) at ART initiation, 522 cells/mm3 (IQR 426-713, n=eight) at one month, and 406 cells/mm3 (IQR 400-452, n=five) at three months. Only 11 partners were notified through the index patient; nine of them were HIV-negative and offered prevention methods, and two were HIV-positive.
CONCLUSION
Identifying and treating AHI in a routine outpatient setting can contribute to linkage with prompt HIV diagnosis and treatment. Conceivably, this could help contribute towards epidemic control in high HIV incidence settings. However, contact tracing and rapid linkage to care are vital challenges that need to be addressed.
CONFLICTS OF INTEREST
None declared.
Acute HIV infection (AHI) cannot be detected with routine point-of-care antibody tests and is rarely diagnosed in resource-limited settings. However, characteristics of AHI, including its non-specific clinical presentation accompanied by high levels of plasma viraemia, may contribute to uncontrolled onward transmission within high-prevalence settings. Improving early detection of AHI in such settings could conceivably contribute to reducing onward transmission and thus impact on HIV elimination goals. We aimed to assess the programmatic feasibility of identifying and treating AHI patients in Eswatini, which has already achieved 90-90-90 targets.
METHODS
From March to December 2019, adults aged 16-49 years and attending outpatient departments at Nhlangano Health Center were screened for symptoms suggestive of AHI, including fever, sore throat, and current symptoms of a sexually transmitted infection. Individuals were enrolled into the study on testing negative or inconclusive for HIV using serial rapid diagnostic tests (RDT) Alere Determine™ HIV-1/2 (Abbott, USA) and Uni-Gold™ HIV (Trinity Biotech, Ireland), and on referral from HIV pre- and post-exposure prophylaxis programmes, if AHI was suspected. AHI was diagnosed using the Xpert platform (Cepheid, Sunnyvale, USA) to perform quantitative HIV RNA detection. Patients with AHI were offered immediate initiation of antiretroviral therapy (ART), follow-up care, and assisted partner notification.
ETHICS
This study was approved by the National Health Research and Review Board, Eswatini, and the MSF Ethics Review Board.
RESULTS
Of 2177 patients initially screened, 997 (46%) had symptoms suggestive of AHI. Of those, 611 (61%) patients were enrolled and tested with Xpert to assay HIV RNA viral load; this included n=586 because their HIV RDT test was negative; n=12 because HIV RDT was inconclusive; and seven and six were presumptive AHI cases identified in the pre- and post-exposure prophylaxis programmes respectively. Of those enrolled, 26 (4.3%) had a detectable HIV viral load. Median viral load was 4.70 log10 (interquartile range (IQR), 3.70-5.96). The most common complaints of those with AHI were fever, sore throat, headache, genital discharge and lower abdominal pain. 16 (62%) patients initiated ART. After two weeks, eight of 11 patients who were followed up had a suppressed viral load below 1000 copies/ml, and by three months, all patients who were on treatment achieved virological suppression. CD4 count was scheduled at every visit and among those with available test results, the median CD4 count was 476 cells/mm3 (IQR 305-768, n=16) at ART initiation, 522 cells/mm3 (IQR 426-713, n=eight) at one month, and 406 cells/mm3 (IQR 400-452, n=five) at three months. Only 11 partners were notified through the index patient; nine of them were HIV-negative and offered prevention methods, and two were HIV-positive.
CONCLUSION
Identifying and treating AHI in a routine outpatient setting can contribute to linkage with prompt HIV diagnosis and treatment. Conceivably, this could help contribute towards epidemic control in high HIV incidence settings. However, contact tracing and rapid linkage to care are vital challenges that need to be addressed.
CONFLICTS OF INTEREST
None declared.
Conference Material > Abstract
Aung A, Daka M, Tamrat A, Gwitima T, Chidhuro T, et al.
MSF Scientific Days International 2021: Innovation. 2021 May 20
WHAT CHALLENGE OR OPPORTUNITY DID YOU TRY TO ADDRESS? WERE EXISTING SOLUTIONS NOT AVAILABLE OR NOT GOOD ENOUGH?
The COVID-19 pandemic has prompted lockdown measures in many places, but patients continued to travel for essential health services. Since COVID-19 has potentially adverse health outcomes among patients with drug-resistant tuberculosis (DR-TB), innovative strategies for medication adherence that minimise travel and the chance of exposure are needed.
WHY DOES THIS CHALLENGE OR OPPORTUNITY MATTER – WHY SHOULD MSF ADDRESS IT?
Historically, directly observed therapy (DOT) has been provided in health facilities, requiring patient travel, or by community treatment supporters (CTS), who travel to patients. The World Health Organisation (WHO) recommends the use of digital methods to support treatment adherence. In response to the COVID-19 pandemic and in collaboration with the National Tuberculosis Control Program (NTCP), we implemented video/virtually observed therapy (VOT) in Shiselweni, Eswatini in May 2020. This allowed the daily observation of patients taking their medication to be done using video messages rather than in-person.
DESCRIBE YOUR INNOVATION AND WHAT MAKES IT INNOVATIVE
The aim of VOT is to support patients with drug adherence using a secured smartphone application. Patients were provided with a sim-implanted, application-installed smartphone with monthly internet subscription and shown how to take and share videos. Nurses reviewed the videos through a web-based dashboard, assessed adherence, and provided feedback. Videos could not be recovered from the smartphone and were retained for a maximum of 45 days on the server.
WHO WILL BENEFIT (WHOSE LIFE / WORK WILL IT IMPROVE?) AND WERE THEY INVOLVED IN THE DESIGN?
Patients who were eligible for VOT (living in network coverage area, smartphone literate, and consented to share videos of themselves) were registered on the web-based platform, which generated login details for the application called SureAdhere©. Those that did not meet the eligibility criteria continued with DOT, provided by community treatment supporters or family treatment supporters.
WHAT OBJECTIVES DID YOU SET FOR THE PROJECT – WHAT DID YOU WANT TO ACHIEVE AND HOW DID YOU DEFINE AND MEASURE SUCCESS (IMPROVED SERVICE, LOWER COST, BETTER EFFICIENCY, BETTER USER EXPERIENCE, ETC.)?
We reviewed patient adherence every month and followed the user experience to understand future scale up. Medical teams and patients also benefitted from instant communication using the application.
WHAT DATA DID YOU COLLECT TO MEASURE THE INNOVATION AGAINST THESE INDICATORS AND HOW DID YOU COLLECT IT? INCLUDE IF YOU DECIDED TO CHANGE THE INDICATORS AND WHY.
The number of patients using VOT for adherence support was collected routinely in the monthly TB register. Individual adherence levels were shown in adherence calendars on the web-based dashboard and nurses produced monthly adherence levels for the VOT cohort.
HOW DID YOU ANALYSE THIS DATA TO UNDERSTAND TO WHAT EXTENT THE INNOVATION ACHIEVED ITS OBJECTIVES? DID THIS INCLUDE A COMPARISON TO THE STATUS QUO OR AN EXISTING SOLUTION?
We retrospectively analysed data to assess VOT uptake among the total DR-TB treatment cohort. Adherence was classified into levels: excellent (100%), good (>90%), or moderate (<90%).
WERE THERE ANY LIMITATIONS TO THE DATA YOU COLLECTED, HOW YOU COLLECTED IT OR HOW YOU ANALYSED IT, OR WERE THERE ANY UNFORESEEN FACTORS THAT MAY HAVE INTERFERED WITH YOUR RESULTS?
We were unable to compare our results with the adherence levels of patients using conventional DOT since routine DOT data was not collected electronically. Some delays in video transmission were experienced due to connectivity issues.
WHAT RESULTS DID YOU GET?
In May 2020, 18 (43%) of 42 patients fulfilled the eligibility criteria and started VOT, increasing to 25 (61%) of 41 patients in November 2020. Two patients using VOT completed treatment with successful outcomes. An adherence level of perfect was observed in all patients undergoing VOT during May and June 2020. Adherence decreased monthly until October 2020 at which 20 (77%) of 26 patients had excellent adherence, four (15%) had good adherence, and two (8%) had moderate adherence. In November 2020, 20 (80%) of 25 patients had perfect adherence and five (20%) had good adherence.
COMPARING THE RESULTS FROM YOUR DATA ANALYSIS TO YOUR OBJECTIVES, EXPLAIN WHY YOU CONSIDER YOUR INNOVATION A SUCCESS OR FAILURE?
We were able to provide adherence support despite the pandemic outbreak. Although average adherence levels did not remain excellent for all patients, the majority of patients achieved favourable adherence, and we were able to quantify adherence using this method.
TO WHAT EXTENT DID THE INNOVATION BENEFIT PEOPLE’S LIVES / WORK?
We implemented VOT relatively swiftly after lockdown measures began in Eswatini, thereby providing timely adherence support to patients with DR-TB.
WHAT ARE THE NEXT STEPS FOR THE INNOVATION ITSELF (SCALE UP, IMPLEMENTATION, FURTHER DEVELOPMENT, DISCONTINUED)?
Uptake of VOT among patients with DR-TB was improving although maintaining perfect adherence was difficult. VOT will be included as an adherence support method for all eligible patients in upcoming research on oral short-course treatment for DR-TB.
IS THE INNOVATION TRANSFERABLE OR ADAPTABLE TO OTHER SETTINGS OR DOMAINS?
The application is straightforward, and the dashboard can be used to easily identify adherence problems to allow for prompt patient support. It gives a clear overview of adherence levels and has enabled direct communication between the patients and healthcare workers.
WHAT BROADER IMPLICATIONS ARE THERE FROM THE INNOVATION FOR MSF AND / OR OTHERS (CHANGE IN PRACTICE, CHANGE IN POLICY, CHANGE IN GUIDELINES, PARADIGM SHIFT)?
In this context, VOT was used to minimise the possibility of physical exposure to SARS-CoV-2 and to overcome COVID-19 travel restrictions. However, the NTCP are interested in using VOT as the standard of care adherence monitoring method for eligible patients in DR-TB programmes.
WHAT OTHER LEARNINGS FROM YOUR WORK ARE IMPORTANT TO SHARE?
VOT was well-received by patients and healthcare workers, although a proportion of patients still preferred in-person DOT. Controlling monthly internet usage and restricting the use of other smartphone applications were required. Data protection advice was sought at headquarters level. Access to the VOT application is password-protected and we are confident that privacy and confidentiality have been respected according to ethics guidelines.
ETHICS
This description and evaluation of an innovation project fulfilled the exemption criteria set by the MSF Ethics Review Board. It was conducted with permission from Monica Rull, Medical Director, Operational Centre Geneva, MSF
The COVID-19 pandemic has prompted lockdown measures in many places, but patients continued to travel for essential health services. Since COVID-19 has potentially adverse health outcomes among patients with drug-resistant tuberculosis (DR-TB), innovative strategies for medication adherence that minimise travel and the chance of exposure are needed.
WHY DOES THIS CHALLENGE OR OPPORTUNITY MATTER – WHY SHOULD MSF ADDRESS IT?
Historically, directly observed therapy (DOT) has been provided in health facilities, requiring patient travel, or by community treatment supporters (CTS), who travel to patients. The World Health Organisation (WHO) recommends the use of digital methods to support treatment adherence. In response to the COVID-19 pandemic and in collaboration with the National Tuberculosis Control Program (NTCP), we implemented video/virtually observed therapy (VOT) in Shiselweni, Eswatini in May 2020. This allowed the daily observation of patients taking their medication to be done using video messages rather than in-person.
DESCRIBE YOUR INNOVATION AND WHAT MAKES IT INNOVATIVE
The aim of VOT is to support patients with drug adherence using a secured smartphone application. Patients were provided with a sim-implanted, application-installed smartphone with monthly internet subscription and shown how to take and share videos. Nurses reviewed the videos through a web-based dashboard, assessed adherence, and provided feedback. Videos could not be recovered from the smartphone and were retained for a maximum of 45 days on the server.
WHO WILL BENEFIT (WHOSE LIFE / WORK WILL IT IMPROVE?) AND WERE THEY INVOLVED IN THE DESIGN?
Patients who were eligible for VOT (living in network coverage area, smartphone literate, and consented to share videos of themselves) were registered on the web-based platform, which generated login details for the application called SureAdhere©. Those that did not meet the eligibility criteria continued with DOT, provided by community treatment supporters or family treatment supporters.
WHAT OBJECTIVES DID YOU SET FOR THE PROJECT – WHAT DID YOU WANT TO ACHIEVE AND HOW DID YOU DEFINE AND MEASURE SUCCESS (IMPROVED SERVICE, LOWER COST, BETTER EFFICIENCY, BETTER USER EXPERIENCE, ETC.)?
We reviewed patient adherence every month and followed the user experience to understand future scale up. Medical teams and patients also benefitted from instant communication using the application.
WHAT DATA DID YOU COLLECT TO MEASURE THE INNOVATION AGAINST THESE INDICATORS AND HOW DID YOU COLLECT IT? INCLUDE IF YOU DECIDED TO CHANGE THE INDICATORS AND WHY.
The number of patients using VOT for adherence support was collected routinely in the monthly TB register. Individual adherence levels were shown in adherence calendars on the web-based dashboard and nurses produced monthly adherence levels for the VOT cohort.
HOW DID YOU ANALYSE THIS DATA TO UNDERSTAND TO WHAT EXTENT THE INNOVATION ACHIEVED ITS OBJECTIVES? DID THIS INCLUDE A COMPARISON TO THE STATUS QUO OR AN EXISTING SOLUTION?
We retrospectively analysed data to assess VOT uptake among the total DR-TB treatment cohort. Adherence was classified into levels: excellent (100%), good (>90%), or moderate (<90%).
WERE THERE ANY LIMITATIONS TO THE DATA YOU COLLECTED, HOW YOU COLLECTED IT OR HOW YOU ANALYSED IT, OR WERE THERE ANY UNFORESEEN FACTORS THAT MAY HAVE INTERFERED WITH YOUR RESULTS?
We were unable to compare our results with the adherence levels of patients using conventional DOT since routine DOT data was not collected electronically. Some delays in video transmission were experienced due to connectivity issues.
WHAT RESULTS DID YOU GET?
In May 2020, 18 (43%) of 42 patients fulfilled the eligibility criteria and started VOT, increasing to 25 (61%) of 41 patients in November 2020. Two patients using VOT completed treatment with successful outcomes. An adherence level of perfect was observed in all patients undergoing VOT during May and June 2020. Adherence decreased monthly until October 2020 at which 20 (77%) of 26 patients had excellent adherence, four (15%) had good adherence, and two (8%) had moderate adherence. In November 2020, 20 (80%) of 25 patients had perfect adherence and five (20%) had good adherence.
COMPARING THE RESULTS FROM YOUR DATA ANALYSIS TO YOUR OBJECTIVES, EXPLAIN WHY YOU CONSIDER YOUR INNOVATION A SUCCESS OR FAILURE?
We were able to provide adherence support despite the pandemic outbreak. Although average adherence levels did not remain excellent for all patients, the majority of patients achieved favourable adherence, and we were able to quantify adherence using this method.
TO WHAT EXTENT DID THE INNOVATION BENEFIT PEOPLE’S LIVES / WORK?
We implemented VOT relatively swiftly after lockdown measures began in Eswatini, thereby providing timely adherence support to patients with DR-TB.
WHAT ARE THE NEXT STEPS FOR THE INNOVATION ITSELF (SCALE UP, IMPLEMENTATION, FURTHER DEVELOPMENT, DISCONTINUED)?
Uptake of VOT among patients with DR-TB was improving although maintaining perfect adherence was difficult. VOT will be included as an adherence support method for all eligible patients in upcoming research on oral short-course treatment for DR-TB.
IS THE INNOVATION TRANSFERABLE OR ADAPTABLE TO OTHER SETTINGS OR DOMAINS?
The application is straightforward, and the dashboard can be used to easily identify adherence problems to allow for prompt patient support. It gives a clear overview of adherence levels and has enabled direct communication between the patients and healthcare workers.
WHAT BROADER IMPLICATIONS ARE THERE FROM THE INNOVATION FOR MSF AND / OR OTHERS (CHANGE IN PRACTICE, CHANGE IN POLICY, CHANGE IN GUIDELINES, PARADIGM SHIFT)?
In this context, VOT was used to minimise the possibility of physical exposure to SARS-CoV-2 and to overcome COVID-19 travel restrictions. However, the NTCP are interested in using VOT as the standard of care adherence monitoring method for eligible patients in DR-TB programmes.
WHAT OTHER LEARNINGS FROM YOUR WORK ARE IMPORTANT TO SHARE?
VOT was well-received by patients and healthcare workers, although a proportion of patients still preferred in-person DOT. Controlling monthly internet usage and restricting the use of other smartphone applications were required. Data protection advice was sought at headquarters level. Access to the VOT application is password-protected and we are confident that privacy and confidentiality have been respected according to ethics guidelines.
ETHICS
This description and evaluation of an innovation project fulfilled the exemption criteria set by the MSF Ethics Review Board. It was conducted with permission from Monica Rull, Medical Director, Operational Centre Geneva, MSF
Journal Article > ResearchFull Text
BMC Infect Dis. 2024 August 15; Volume 24 (Issue 1); 829.; DOI:10.1186/s12879-024-09744-9
Mukooza E, Schausberger B, Mmema N, Dlamini V, Aung A, et al.
BMC Infect Dis. 2024 August 15; Volume 24 (Issue 1); 829.; DOI:10.1186/s12879-024-09744-9
BACKGROUND
Improving treatment success rates among multi drug-resistant tuberculosis (MDR-TB) patients is critical to reducing its incidence and mortality, but adherence poses an important challenge. Video-based direct observed therapy (vDOT) may provide adherence benefits, while addressing the time and cost burden associated with community treatment supporter (CTS)-DOT. This study explored experiences of patients, family members and healthcare workers with different DOT modalities for adherence support in Eswatini.
METHODS
Between April 2021 and May 2022, thirteen men and five women with MDR-TB, ten healthcare workers, and nine caregivers were purposively sampled to include a range of characteristics and experiences with DOT modalities. Data were generated through individual in-depth interviews and a smartphone messaging application (WhatsApp). Data coding was undertaken iteratively, and thematic analysis undertaken, supported by Nvivo.
RESULTS
Four themes emerged that reflected participants’ experiences with different DOT modalities, including stigma, efficiency, perceived risks of TB acquisition, and patient autonomy. vDOT was appreciated by patients for providing them with privacy and shielding them from stigmatisation associated with being seen in TB clinics or with community treatment supporters. vDOT was also seen as more efficient than CTS-DOT. Health workers acknowledged that it saved time, allowing them to attend to more patients, while many patients found vDOT more convenient and less expensive by removing the need to travel for in-person consultations. Health workers also appreciated vDOT because it reduced risks of TB acquisition by minimising exposure through virtual patient monitoring. Although many patients appreciated greater autonomy in managing their illness through vDOT, others preferred human contact or struggled with making video recordings. Most family members appreciated vDOT, although some resented feeling removed from the process of supporting loved ones.
CONCLUSIONS
vDOT was generally appreciated by MDR-TB patients, their family members and health workers as it addressed barriers to adherence which could contribute to improved treatment completion rates and reduced workplace exposure. However, patients should be offered an alternative to vDOT such as CTS-DOT if this modality does not suit their circumstances or preferences.
Conference Material > Poster
Kerschberger B, Mpala Q, Aung A, Ntshalintshali N, Mamba C, et al.
MSF Scientific Days International 2021: Research. 2021 May 18
Journal Article > ResearchFull Text
AIDS Care. 2024 March 1; Volume 36 (Issue 3); 308-313.; DOI:10.1080/13548506.2023.2235275
Mukooza E, Schausberger B, Mmema N, Dlamini V, Aung A, et al.
AIDS Care. 2024 March 1; Volume 36 (Issue 3); 308-313.; DOI:10.1080/13548506.2023.2235275
Acute and early HIV infection (AEHI) is rarely diagnosed in sub-Saharan Africa, despite its potential contribution to incidence reduction. This qualitative study in Eswatini explored the experiences of health workers, people diagnosed with AEHI, and their partners towards AEHI diagnosis, to inform its scale-up. In-depth interviews were undertaken with 11 women and four men diagnosed with AEHI. Three patients’ partners were interviewed about their understanding of AEHI and six health workers were interviewed about experiences of delivering AEHI services. Data were coded inductively and analysed iteratively following the principles of grounded theory. Experiences with AEHI diagnoses were shaped by (i) understanding the nature and consequences of AEHI, and (ii) social norms that influence disclosure and sexual behaviour. AEHI was a new concept for health workers who struggled to explain it to patients, leading to some confusion over their HIV status and misunderstandings around its high transmissibility and prognosis. Disclosure tended to occur to primary partners, if at all, limiting the ability to provide partner services, and one relationship breakdown was reported. If AEHI diagnosis and care interventions are to realise their full potential, it will be essential to reinforce the accompanying counselling sessions and closely monitor for potential social harms.