Journal Article > ResearchFull Text
BMC Health Serv Res. 2024 June 3; Volume 24 (Issue 1); 699.; DOI:10.1186/s12913-024-11151-4
Kerschberger B, Daka M, Shongwe B, Dlamini T, Ngwenya S, et al.
BMC Health Serv Res. 2024 June 3; Volume 24 (Issue 1); 699.; DOI:10.1186/s12913-024-11151-4
BACKGROUND
Video-enabled directly observed therapy (video-DOT) has been proposed as an additional option for treatment provision besides in-person DOT for patients with drug-resistant TB (DRTB) disease. However, evidence and implementation experience mainly originate from well-resourced contexts. This study describes the operationalization of video-DOT in a low-resourced setting in Eswatini facing a high burden of HIV and TB amid the emergence of the COVID-19 pandemic.
METHODS
This is a retrospectively established cohort of patients receiving DRTB treatment during the implementation of video-DOT in Shiselweni from May 2020 to March 2022. We described intervention uptake (vs. in-person DOT) and assessed unfavorable DRTB treatment outcome (death, loss to care) using Kaplan-Meier statistics and multivariable Cox-regression models. Video-related statistics were described with frequencies and medians. We calculated the fraction of expected doses observed (FEDO) under video-DOT and assessed associations with missed video uploads using multivariable Poisson regression analysis.
RESULTS
Of 71 DRTB patients eligible for video-DOT, the median age was 39 (IQR 30–54) years, 31.0% (n = 22) were women, 67.1% (n = 47/70) were HIV-positive, and 42.3% (n = 30) were already receiving DRTB treatment when video-DOT became available. About half of the patients (n = 37; 52.1%) chose video-DOT, mostly during the time when COVID-19 appeared in Eswatini. Video-DOT initiations were lower in new DRTB patients (aHR 0.24, 95% CI 0.12–0.48) and those aged ≥ 60 years (aHR 0.27, 95% CI 0.08–0.89). Overall, 20,634 videos were uploaded with a median number of 553 (IQR 309–748) videos per patient and a median FEDO of 92% (IQR 84–97%). Patients aged ≥ 60 years were less likely to miss video uploads (aIRR 0.07, 95% CI 0.01–0.51). The cumulative Kaplan-Meier estimate of an unfavorable treatment outcome among all patients was 0.08 (95% CI 0.03–0.19), with no differences detected by DOT approach and other baseline factors in multivariable analysis.
CONCLUSIONS
Implementing video-DOT for monitoring of DRTB care provision amid the intersection of the HIV and COVID-19 pandemics seemed feasible. Digital health technologies provide additional options for patients to choose their preferred way to support treatment taking, thus possibly increasing patient-centered health care while sustaining favorable treatment outcomes.
Video-enabled directly observed therapy (video-DOT) has been proposed as an additional option for treatment provision besides in-person DOT for patients with drug-resistant TB (DRTB) disease. However, evidence and implementation experience mainly originate from well-resourced contexts. This study describes the operationalization of video-DOT in a low-resourced setting in Eswatini facing a high burden of HIV and TB amid the emergence of the COVID-19 pandemic.
METHODS
This is a retrospectively established cohort of patients receiving DRTB treatment during the implementation of video-DOT in Shiselweni from May 2020 to March 2022. We described intervention uptake (vs. in-person DOT) and assessed unfavorable DRTB treatment outcome (death, loss to care) using Kaplan-Meier statistics and multivariable Cox-regression models. Video-related statistics were described with frequencies and medians. We calculated the fraction of expected doses observed (FEDO) under video-DOT and assessed associations with missed video uploads using multivariable Poisson regression analysis.
RESULTS
Of 71 DRTB patients eligible for video-DOT, the median age was 39 (IQR 30–54) years, 31.0% (n = 22) were women, 67.1% (n = 47/70) were HIV-positive, and 42.3% (n = 30) were already receiving DRTB treatment when video-DOT became available. About half of the patients (n = 37; 52.1%) chose video-DOT, mostly during the time when COVID-19 appeared in Eswatini. Video-DOT initiations were lower in new DRTB patients (aHR 0.24, 95% CI 0.12–0.48) and those aged ≥ 60 years (aHR 0.27, 95% CI 0.08–0.89). Overall, 20,634 videos were uploaded with a median number of 553 (IQR 309–748) videos per patient and a median FEDO of 92% (IQR 84–97%). Patients aged ≥ 60 years were less likely to miss video uploads (aIRR 0.07, 95% CI 0.01–0.51). The cumulative Kaplan-Meier estimate of an unfavorable treatment outcome among all patients was 0.08 (95% CI 0.03–0.19), with no differences detected by DOT approach and other baseline factors in multivariable analysis.
CONCLUSIONS
Implementing video-DOT for monitoring of DRTB care provision amid the intersection of the HIV and COVID-19 pandemics seemed feasible. Digital health technologies provide additional options for patients to choose their preferred way to support treatment taking, thus possibly increasing patient-centered health care while sustaining favorable treatment outcomes.
Other > Pre-Print
BMC Health Serv Res. 2023 August 9; DOI:10.21203/rs.3.rs-3135109/v1
Kerschberger B, Daka M, Shongwe B, Dlamini T, Ngwenya SM, et al.
BMC Health Serv Res. 2023 August 9; DOI:10.21203/rs.3.rs-3135109/v1
BACKGROUND
Video-enabled directly observed therapy (video-DOT) has been proposed as an additional option for treatment provision besides in-person DOT for patients with drug-resistant TB (DRTB) disease. However, evidence and implementation experience mainly originate from well-resourced contexts. This study describes the operationalization of video-DOT in a low-resourced setting in Eswatini facing a high burden of HIV and TB amid the emergence of the COVID-19 pandemic.
METHODS
This is a retrospectively established cohort of patients receiving DRTB treatment during the implementation of video-DOT in Shiselweni from May 2020 to March 2022. We described intervention uptake (vs in-person DOT) and assessed unfavorable DRTB treatment outcome (death, loss to care) using Kaplan-Meier statistics and multivariable Cox-regression models. Video-related statistics were described with frequencies and medians. We calculated the fraction of expected doses observed (FEDO) under video-DOT and assessed associations with missed video uploads using multivariable Poisson regression analysis.
RESULTS
Of 71 DRTB patients eligible for video-DOT, the median age was 39 (IQR 30–54) years, 31.0% (n=22) were women, 67.1% (n=47/70) were HIV-positive, and 42.3% (n=30) were already receiving DRTB treatment when video-DOT became available. About half of the patients (n=37; 52.1%) chose video-DOT, mostly during the time when COVID-19 appeared in Eswatini. Video-DOT initiations were lower in new DRTB patients (aHR 0.24, 95% CI 0.12–0.48) and those aged =60 years (aHR 0.27, 95% CI 0.08–0.89). Overall, 20,634 videos were uploaded with a median number of 553 (IQR 309–748) videos per patient and a median FEDO of 92% (IQR 84–97%). Patients aged =60 years were less likely to miss video uploads (aIRR 0.07, 95% CI 0.01–0.51). The cumulative Kaplan-Meier estimate of an unfavorable treatment outcome among all patients was 0.08 (95% CI 0.03–0.19), with no differences detected by DOT approach and other baseline factors in multivariable analysis.
CONCLUSIONS
Implementing video-DOT for monitoring of DRTB care provision amid the intersection of the HIV and COVID-19 pandemics seemed feasible. Digital health technologies provide additional options for patients to choose their preferred way to support treatment taking, thus possibly increasing patient-centered health care while sustaining favorable treatment outcomes.
Video-enabled directly observed therapy (video-DOT) has been proposed as an additional option for treatment provision besides in-person DOT for patients with drug-resistant TB (DRTB) disease. However, evidence and implementation experience mainly originate from well-resourced contexts. This study describes the operationalization of video-DOT in a low-resourced setting in Eswatini facing a high burden of HIV and TB amid the emergence of the COVID-19 pandemic.
METHODS
This is a retrospectively established cohort of patients receiving DRTB treatment during the implementation of video-DOT in Shiselweni from May 2020 to March 2022. We described intervention uptake (vs in-person DOT) and assessed unfavorable DRTB treatment outcome (death, loss to care) using Kaplan-Meier statistics and multivariable Cox-regression models. Video-related statistics were described with frequencies and medians. We calculated the fraction of expected doses observed (FEDO) under video-DOT and assessed associations with missed video uploads using multivariable Poisson regression analysis.
RESULTS
Of 71 DRTB patients eligible for video-DOT, the median age was 39 (IQR 30–54) years, 31.0% (n=22) were women, 67.1% (n=47/70) were HIV-positive, and 42.3% (n=30) were already receiving DRTB treatment when video-DOT became available. About half of the patients (n=37; 52.1%) chose video-DOT, mostly during the time when COVID-19 appeared in Eswatini. Video-DOT initiations were lower in new DRTB patients (aHR 0.24, 95% CI 0.12–0.48) and those aged =60 years (aHR 0.27, 95% CI 0.08–0.89). Overall, 20,634 videos were uploaded with a median number of 553 (IQR 309–748) videos per patient and a median FEDO of 92% (IQR 84–97%). Patients aged =60 years were less likely to miss video uploads (aIRR 0.07, 95% CI 0.01–0.51). The cumulative Kaplan-Meier estimate of an unfavorable treatment outcome among all patients was 0.08 (95% CI 0.03–0.19), with no differences detected by DOT approach and other baseline factors in multivariable analysis.
CONCLUSIONS
Implementing video-DOT for monitoring of DRTB care provision amid the intersection of the HIV and COVID-19 pandemics seemed feasible. Digital health technologies provide additional options for patients to choose their preferred way to support treatment taking, thus possibly increasing patient-centered health care while sustaining favorable treatment outcomes.
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
Conference Material > Slide Presentation
Daka M
MSF Scientific Days International 2021: Innovation. 2021 May 20
Conference Material > Slide Presentation
Kerschberger B, Mukooza E, Berto A, Ntshalintshali N, Mafomisa M, et al.
MSF Scientific Day International 2023. 2023 June 7; DOI:10.57740/h6j7-s634
Conference Material > Abstract
Kerschberger B, Ntshalintshali N, Mafomisa M, Mabhena E, Daka M, et al.
MSF Scientific Day International 2023. 2023 June 7; DOI:10.57740/4e0e-e138
INTRODUCTION
Sexually transmitted infections (STI’s) are a public health threat. Syndromic approaches based on clinical symptoms have been suggested as having poor diagnostic performance, particularly in the type of settings where MSF is operational. We assessed the burden of STI’s and the diagnostic performance of a syndromic approach within an MSF-supported HIV/STI project in Eswatini.
METHODS
We conducted a cross-sectional study, enrolling adults accessing routine HIV testing and antiretroviral care services in six clinics in Shiselweni, from July 2022 to January 2023. HIV testing counselors performed HIV testing and nurses assessed patients for STI’s. Laboratory investigations included antibody-based rapid diagnostic tests (RDT’s) for Treponema pallidum (TP), hepatitis B (HBV) and hepatitis C (HBC). The molecular platform Xpert was used to test urine samples for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG), Trichomonas vaginalis (TV), Mycoplasma genitalium (MG), vaginal/anal swabs for human papillomavirus (HPV), and plasma for HIV viraemia to test for acute HIV infection (HIV). We calculated the prevalence of STI’s, and assessed diagnostic performance of a syndromic approach to diagnose male urethritis (MUS) and vaginal discharge (VDS) syndromes, versus laboratory-based testing.
ETHICS
This study was approved by the Eswatini Health and Human Research Review Board and by the MSF Ethics Review Board.
RESULTS
Of 1,041 study participants, 682 were women (65.5%), and the median age was 30 (interquartile range, IQR, 24-38) years. Overall, 280 (26.9%) were known HIV-positive and of 755 with unknown HIV status, 30 (4.0%) were newly diagnosed with HIV, of whom seven (23.3%) had AHI. 308 (29.6%) patients had at least one of the following three pathogens identified: NG 121 (11.6%); CT 155 (14.9%); TV 109 (10.5%). MG was detected in 33/330 participants (10.0%). In addition, 105 (10.1%) had antibodies against TP, 49 (4.7%) against HBV, and three (0.3%) against HCV. HPV prevalence was higher in tested women (104/196; 53.1%) versus men (5/27; 18.5%; p=0.001). Prevalence of NG/CT/TP was highest in newly-diagnosed HIV cases (48.2%) versus known HIV-positive cases (26.8%, p=0.019). Based on the syndromic approach, 188/634 (29.7%) had a VDS, and 97/334 (29.0%) a MUS. Diagnostic performance of the syndromic approach was better in men (MUS: sensitivity: 66.7%, specificity 87.5%; positive predictive value, PPV, 70.1%, negative predictive value, NPV, 85.7%), versus women (VDS: sensitivity 35.9%, specificity 72.9%; PPV 35.1%, NPV 73.5%).
CONCLUSION
A high burden of STI’s in Eswatini and poor diagnostic ability of the syndromic approach in this setting, calls for new approaches for STI care in MSF-supported sexual and reproductive health programmes in resource-poor settings.
CONFLICTS OF INTEREST
None declared
Sexually transmitted infections (STI’s) are a public health threat. Syndromic approaches based on clinical symptoms have been suggested as having poor diagnostic performance, particularly in the type of settings where MSF is operational. We assessed the burden of STI’s and the diagnostic performance of a syndromic approach within an MSF-supported HIV/STI project in Eswatini.
METHODS
We conducted a cross-sectional study, enrolling adults accessing routine HIV testing and antiretroviral care services in six clinics in Shiselweni, from July 2022 to January 2023. HIV testing counselors performed HIV testing and nurses assessed patients for STI’s. Laboratory investigations included antibody-based rapid diagnostic tests (RDT’s) for Treponema pallidum (TP), hepatitis B (HBV) and hepatitis C (HBC). The molecular platform Xpert was used to test urine samples for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG), Trichomonas vaginalis (TV), Mycoplasma genitalium (MG), vaginal/anal swabs for human papillomavirus (HPV), and plasma for HIV viraemia to test for acute HIV infection (HIV). We calculated the prevalence of STI’s, and assessed diagnostic performance of a syndromic approach to diagnose male urethritis (MUS) and vaginal discharge (VDS) syndromes, versus laboratory-based testing.
ETHICS
This study was approved by the Eswatini Health and Human Research Review Board and by the MSF Ethics Review Board.
RESULTS
Of 1,041 study participants, 682 were women (65.5%), and the median age was 30 (interquartile range, IQR, 24-38) years. Overall, 280 (26.9%) were known HIV-positive and of 755 with unknown HIV status, 30 (4.0%) were newly diagnosed with HIV, of whom seven (23.3%) had AHI. 308 (29.6%) patients had at least one of the following three pathogens identified: NG 121 (11.6%); CT 155 (14.9%); TV 109 (10.5%). MG was detected in 33/330 participants (10.0%). In addition, 105 (10.1%) had antibodies against TP, 49 (4.7%) against HBV, and three (0.3%) against HCV. HPV prevalence was higher in tested women (104/196; 53.1%) versus men (5/27; 18.5%; p=0.001). Prevalence of NG/CT/TP was highest in newly-diagnosed HIV cases (48.2%) versus known HIV-positive cases (26.8%, p=0.019). Based on the syndromic approach, 188/634 (29.7%) had a VDS, and 97/334 (29.0%) a MUS. Diagnostic performance of the syndromic approach was better in men (MUS: sensitivity: 66.7%, specificity 87.5%; positive predictive value, PPV, 70.1%, negative predictive value, NPV, 85.7%), versus women (VDS: sensitivity 35.9%, specificity 72.9%; PPV 35.1%, NPV 73.5%).
CONCLUSION
A high burden of STI’s in Eswatini and poor diagnostic ability of the syndromic approach in this setting, calls for new approaches for STI care in MSF-supported sexual and reproductive health programmes in resource-poor settings.
CONFLICTS OF INTEREST
None declared
Journal Article > ResearchFull Text
Trop Med Int Health. 2024 March 1; Volume 29 (Issue 3); 192-205.; DOI:10.1111/tmi.13961
Kerschberger B, Vambe D, Schomaker M, Mabhena E, Daka M, et al.
Trop Med Int Health. 2024 March 1; Volume 29 (Issue 3); 192-205.; DOI:10.1111/tmi.13961
OBJECTIVES
Despite declining TB notifications in Southern Africa, TB‐related deaths remain high. We describe patient‐ and population‐level trends in TB‐related deaths in Eswatini over a period of 11 years.
METHODS
Patient‐level (retrospective cohort, from 2009 to 2019) and population‐level (ecological analysis, 2009–2017) predictors and rates of TB‐related deaths were analysed in HIV‐negative and HIV‐coinfected first‐line TB treatment cases and the population of the Shiselweni region. Patient‐level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient‐level and population‐level predictors of deaths.
RESULTS
Of 11,883 TB treatment cases, 1,302 (11.0%) patients died during treatment: 210/2,798 (7.5%) HIV‐negative patients, 984/8,443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV‐status. The treatment case fatality ratio remained above 10% in most years. At patient‐level, fatality risk was higher in PLHIV (aRR 1.74, 1.51–2.02), and for older age and extra‐pulmonary TB irrespective of HIV‐status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18–1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47–1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB‐LAM testing (aRR 0.65, 0.35–0.90). At population‐level, mortality rates decreased 6.4‐fold (−147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2,785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (−826/100,000 vs. HIV‐negative: −23/100,000), the relative population‐level mortality risk remained higher in PLHIV (aRR 4.68, 3.25–6.72) compared to the HIV‐negative population.
CONCLUSIONS
TB‐related mortality rapidly decreased at population‐level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.
Despite declining TB notifications in Southern Africa, TB‐related deaths remain high. We describe patient‐ and population‐level trends in TB‐related deaths in Eswatini over a period of 11 years.
METHODS
Patient‐level (retrospective cohort, from 2009 to 2019) and population‐level (ecological analysis, 2009–2017) predictors and rates of TB‐related deaths were analysed in HIV‐negative and HIV‐coinfected first‐line TB treatment cases and the population of the Shiselweni region. Patient‐level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient‐level and population‐level predictors of deaths.
RESULTS
Of 11,883 TB treatment cases, 1,302 (11.0%) patients died during treatment: 210/2,798 (7.5%) HIV‐negative patients, 984/8,443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV‐status. The treatment case fatality ratio remained above 10% in most years. At patient‐level, fatality risk was higher in PLHIV (aRR 1.74, 1.51–2.02), and for older age and extra‐pulmonary TB irrespective of HIV‐status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18–1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47–1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB‐LAM testing (aRR 0.65, 0.35–0.90). At population‐level, mortality rates decreased 6.4‐fold (−147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2,785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (−826/100,000 vs. HIV‐negative: −23/100,000), the relative population‐level mortality risk remained higher in PLHIV (aRR 4.68, 3.25–6.72) compared to the HIV‐negative population.
CONCLUSIONS
TB‐related mortality rapidly decreased at population‐level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.
Conference Material > Video (talk)
Daka M
MSF Scientific Days International 2021: Innovation. 2021 May 20
Conference Material > Poster
Mukooza E, Mmema N, Dlamini V, Dlamini SV, Mafomisa M, et al.
MSF Scientific Day International 2024. 2024 May 16; DOI:10.57740/sIAFR9icQ