Journal Article > ResearchAbstract Only
Int J Tuberc Lung Dis. 2018 September 1; Volume 22 (Issue 9); 1023-1030.; DOI:10.5588/ijtld.17.0826
Snyman L, Venables E, Trivino Duran L, Mohr E, Azevedo VD, et al.
Int J Tuberc Lung Dis. 2018 September 1; Volume 22 (Issue 9); 1023-1030.; DOI:10.5588/ijtld.17.0826
SETTING
Early interventions for patients who interrupt their treatment for drug-resistant tuberculosis (DR-TB) are rarely reported and assessed. A novel, patient-centred intervention for patients at risk of loss to follow-up (LTFU) from DR-TB treatment was implemented in Khayelitsha, South Africa, in September 2013.
OBJECTIVE
To explore the experiences and perceptions of patients, key support persons, health care workers (HCWs) and programme managers of a patient-centred model.
DESIGN
This was a qualitative study consisting of 18 in-depth interviews with patients, key support persons, HCWs, key informants and one focus group discussion with HCWs, between July and September 2017. Data were coded and thematically analysed.
RESULTS
The model was well perceived and viewed positively by patients, care providers and programme managers. 'Normalisation' and tolerance of occasional treatment interruptions, tracing, tailored management plans and peer support were perceived to be beneficial for retaining patients in care. Although the model was resource-demanding, health workers were convinced that it 'needs to be sustained,' and proposed solutions for its standardisation.
CONCLUSION
An intervention based on early tracing of patients who interrupt treatment, peer-delivered counselling and individualised management plans by a multidisciplinary team was considered a beneficial and acceptable model to support patients at risk of LTFU from DR-TB treatment.
Early interventions for patients who interrupt their treatment for drug-resistant tuberculosis (DR-TB) are rarely reported and assessed. A novel, patient-centred intervention for patients at risk of loss to follow-up (LTFU) from DR-TB treatment was implemented in Khayelitsha, South Africa, in September 2013.
OBJECTIVE
To explore the experiences and perceptions of patients, key support persons, health care workers (HCWs) and programme managers of a patient-centred model.
DESIGN
This was a qualitative study consisting of 18 in-depth interviews with patients, key support persons, HCWs, key informants and one focus group discussion with HCWs, between July and September 2017. Data were coded and thematically analysed.
RESULTS
The model was well perceived and viewed positively by patients, care providers and programme managers. 'Normalisation' and tolerance of occasional treatment interruptions, tracing, tailored management plans and peer support were perceived to be beneficial for retaining patients in care. Although the model was resource-demanding, health workers were convinced that it 'needs to be sustained,' and proposed solutions for its standardisation.
CONCLUSION
An intervention based on early tracing of patients who interrupt treatment, peer-delivered counselling and individualised management plans by a multidisciplinary team was considered a beneficial and acceptable model to support patients at risk of LTFU from DR-TB treatment.
Journal Article > ResearchFull Text
BMJ Open. 2020 July 8; Volume 10 (Issue 7); e037545.; DOI:10.1136/bmjopen-2020-037545.
Keene CM, Zokufa N, Venables E, Wilkinson LS, Hoffman R, et al.
BMJ Open. 2020 July 8; Volume 10 (Issue 7); e037545.; DOI:10.1136/bmjopen-2020-037545.
OBJECTIVE
Longer intervals between routine clinic visits and medication refills are part of patient-centred, differentiated service delivery (DSD). They have been shown to improve patient outcomes as well as optimise health services—vital as ‘universal test-and-treat’ targets increase numbers of HIV patients on antiretroviral treatment (ART). This qualitative study explored patient, healthcare worker and key informant experiences and perceptions of extending ART refills to 6 months in adherence clubs in Khayelitsha, South Africa.
DESIGN AND SETTING
In-depth interviews were conducted in isiXhosa with purposively selected patients and in English with healthcare workers and key informants. All transcripts were audio-recorded, transcribed and translated to English, manually coded and thematically analysed. The participants had been involved in a randomised controlled trial evaluating multi-month ART dispensing in adherence clubs, comparing 6-month and 2-month refills.
PARTICIPANTS
Twenty-three patients, seven healthcare workers and six key informants.
RESULTS
Patients found that 6-month refills increased convenience and reduced unintended disclosure. Contrary to key informant concerns about patients’ responsibility to manage larger quantities of ART, patients receiving 6-month refills were highly motivated and did not face challenges transporting, storing or adhering to treatment. All participant groups suggested that strict eligibility criteria were necessary for patients to realise the benefits of extended dispensing intervals. Six-month refills were felt to increase health system efficiency, but there were concerns about whether the existing drug supply system could adapt to 6-month refills on a larger scale.
CONCLUSIONS
Patients, healthcare workers and key informants found 6-month refills within adherence clubs acceptable and beneficial, but concerns were raised about the reliability of the supply chain to manage extended multi-month dispensing. Stepwise, slow expansion could avoid overstressing supply and allow time for the health system to adapt, permitting 6-month ART refills to enhance current DSD options to be more efficient and patient-centred within current health system constraints.
Longer intervals between routine clinic visits and medication refills are part of patient-centred, differentiated service delivery (DSD). They have been shown to improve patient outcomes as well as optimise health services—vital as ‘universal test-and-treat’ targets increase numbers of HIV patients on antiretroviral treatment (ART). This qualitative study explored patient, healthcare worker and key informant experiences and perceptions of extending ART refills to 6 months in adherence clubs in Khayelitsha, South Africa.
DESIGN AND SETTING
In-depth interviews were conducted in isiXhosa with purposively selected patients and in English with healthcare workers and key informants. All transcripts were audio-recorded, transcribed and translated to English, manually coded and thematically analysed. The participants had been involved in a randomised controlled trial evaluating multi-month ART dispensing in adherence clubs, comparing 6-month and 2-month refills.
PARTICIPANTS
Twenty-three patients, seven healthcare workers and six key informants.
RESULTS
Patients found that 6-month refills increased convenience and reduced unintended disclosure. Contrary to key informant concerns about patients’ responsibility to manage larger quantities of ART, patients receiving 6-month refills were highly motivated and did not face challenges transporting, storing or adhering to treatment. All participant groups suggested that strict eligibility criteria were necessary for patients to realise the benefits of extended dispensing intervals. Six-month refills were felt to increase health system efficiency, but there were concerns about whether the existing drug supply system could adapt to 6-month refills on a larger scale.
CONCLUSIONS
Patients, healthcare workers and key informants found 6-month refills within adherence clubs acceptable and beneficial, but concerns were raised about the reliability of the supply chain to manage extended multi-month dispensing. Stepwise, slow expansion could avoid overstressing supply and allow time for the health system to adapt, permitting 6-month ART refills to enhance current DSD options to be more efficient and patient-centred within current health system constraints.
Journal Article > ResearchFull Text
PLOS One. 2018 September 14; Volume 13 (Issue 9); e0203888.; DOI:10.1371/journal.pone.0203888
Mohr E, Snyman L, Mbakaz Z, Caldwell J, De Azevedo V, et al.
PLOS One. 2018 September 14; Volume 13 (Issue 9); e0203888.; DOI:10.1371/journal.pone.0203888
BACKGROUND
Self-administered treatment (SAT), a differentiated model of care for rifampicin-resistant tuberculosis (RR-TB), might address adherence challenges faced by patients and health care systems. This study explored patient, health-care worker (HCW) and community care worker (CCW) perspectives on a SAT pilot programme in South Africa, in which patients were given medication to take at home with the optional support of a CCW.
METHODS
We conducted a mixed-methods study from July 2016-June 2017. The quantitative component included semi-structured questionnaires with patients, HCWs and CCWs; the qualitative component involved in-depth interviews with patients enrolled in the pilot programme. Interviews were conducted in isiXhosa, translated, transcribed and manually coded.
RESULTS
Overall, 27 patients, 12 HCWs and 44 CCWs were enrolled in the quantitative component; nine patients were also interviewed. Of the 27 patients who completed semi-structured questionnaires, 22 were HIV-infected and 17 received a monthly supply of RR TB treatment. Most HCWs and CCWs (10 and 32, respectively) understood the pilot programme; approximately half (n = 14) of the patients could not correctly describe the pilot programme. Overall, 11 and 41 HCWs and CCWs reported that the pilot programme promoted treatment adherence. Additionally, 11 HCWs reported that the pilot programme relieved pressure on the clinic. Key qualitative findings highlighted the importance of a support person and how the flexibility of SAT enabled integration of treatment into their daily routines and reduced time spent in clinics. The pilot programme was also perceived to allow patients more autonomy and made it easier for them to manage side-effects.
CONCLUSION
The SAT pilot programme was acceptable from the perspective of patients, HCWs and CCWs and should be considered as a differentiated model of care for RR-TB, particularly in settings with high burdens of HIV, in order to ease management of treatment for patients and health-care providers.
Self-administered treatment (SAT), a differentiated model of care for rifampicin-resistant tuberculosis (RR-TB), might address adherence challenges faced by patients and health care systems. This study explored patient, health-care worker (HCW) and community care worker (CCW) perspectives on a SAT pilot programme in South Africa, in which patients were given medication to take at home with the optional support of a CCW.
METHODS
We conducted a mixed-methods study from July 2016-June 2017. The quantitative component included semi-structured questionnaires with patients, HCWs and CCWs; the qualitative component involved in-depth interviews with patients enrolled in the pilot programme. Interviews were conducted in isiXhosa, translated, transcribed and manually coded.
RESULTS
Overall, 27 patients, 12 HCWs and 44 CCWs were enrolled in the quantitative component; nine patients were also interviewed. Of the 27 patients who completed semi-structured questionnaires, 22 were HIV-infected and 17 received a monthly supply of RR TB treatment. Most HCWs and CCWs (10 and 32, respectively) understood the pilot programme; approximately half (n = 14) of the patients could not correctly describe the pilot programme. Overall, 11 and 41 HCWs and CCWs reported that the pilot programme promoted treatment adherence. Additionally, 11 HCWs reported that the pilot programme relieved pressure on the clinic. Key qualitative findings highlighted the importance of a support person and how the flexibility of SAT enabled integration of treatment into their daily routines and reduced time spent in clinics. The pilot programme was also perceived to allow patients more autonomy and made it easier for them to manage side-effects.
CONCLUSION
The SAT pilot programme was acceptable from the perspective of patients, HCWs and CCWs and should be considered as a differentiated model of care for RR-TB, particularly in settings with high burdens of HIV, in order to ease management of treatment for patients and health-care providers.
Journal Article > ResearchFull Text
PLOS One. 2017 May 18; Volume 12 (Issue 5); e0178054.; DOI:10.1371/journal.pone.0178054
Mohr E, Daniels J, Beko B, Isaakidis P, Cox V, et al.
PLOS One. 2017 May 18; Volume 12 (Issue 5); e0178054.; DOI:10.1371/journal.pone.0178054
BACKGROUND
Daily directly-observed therapy (DOT) is recommended for rifampicin-resistant tuberculosis (RR-TB) patients throughout treatment. We assessed the impact of self-administered treatment (SAT) in a South African township with high rates of RR-TB and HIV.
METHODS
Community-supported SAT for patients who completed the intensive phase was piloted in five primary care clinics in Khayelitsha. We compared final treatment outcomes among RR-TB patients initiating treatment before (standard-of-care (SOC)-cohort, January 2010-July 2013) and after the implementation of the pilot (SAT-cohort, January 2012-December 2014). All patients with outcomes before January 1, 2017 were considered in the analysis of outcomes.
RESULTS
One-hundred-eighteen patients in the SOC-cohort and 174 patients in the SAT-cohort had final RR-TB treatment outcomes; 70% and 73% were HIV-co-infected, respectively. The proportion of patients with a final outcome of loss to follow-up (LTFU) did not differ whether treated in the SOC (25/118, 21.2%) or SAT-cohort (31/174, 17.8%) (P = 0.47). There were no significant differences in the time to 24-month LTFU among HIV-infected and uninfected patients (HR 0.90, 95% CI: 0.51-1.6, P = 0.71), or among patients enrolled in the SOC-cohort versus the SAT-cohort (HR 0.83, 95% CI: 0.49-1.4, P = 0.50) who received at least 6-months of RR-TB treatment.
CONCLUSION
The introduction of SAT during the continuation phase of RR-TB treatment does not adversely affect final RR-TB treatment outcomes in a high TB and HIV-burden setting. This differentiated, patient-centred model of care could be considered in RR-TB programmes to decrease the burden of DOT on patients and health facilities.
Daily directly-observed therapy (DOT) is recommended for rifampicin-resistant tuberculosis (RR-TB) patients throughout treatment. We assessed the impact of self-administered treatment (SAT) in a South African township with high rates of RR-TB and HIV.
METHODS
Community-supported SAT for patients who completed the intensive phase was piloted in five primary care clinics in Khayelitsha. We compared final treatment outcomes among RR-TB patients initiating treatment before (standard-of-care (SOC)-cohort, January 2010-July 2013) and after the implementation of the pilot (SAT-cohort, January 2012-December 2014). All patients with outcomes before January 1, 2017 were considered in the analysis of outcomes.
RESULTS
One-hundred-eighteen patients in the SOC-cohort and 174 patients in the SAT-cohort had final RR-TB treatment outcomes; 70% and 73% were HIV-co-infected, respectively. The proportion of patients with a final outcome of loss to follow-up (LTFU) did not differ whether treated in the SOC (25/118, 21.2%) or SAT-cohort (31/174, 17.8%) (P = 0.47). There were no significant differences in the time to 24-month LTFU among HIV-infected and uninfected patients (HR 0.90, 95% CI: 0.51-1.6, P = 0.71), or among patients enrolled in the SOC-cohort versus the SAT-cohort (HR 0.83, 95% CI: 0.49-1.4, P = 0.50) who received at least 6-months of RR-TB treatment.
CONCLUSION
The introduction of SAT during the continuation phase of RR-TB treatment does not adversely affect final RR-TB treatment outcomes in a high TB and HIV-burden setting. This differentiated, patient-centred model of care could be considered in RR-TB programmes to decrease the burden of DOT on patients and health facilities.
Journal Article > CommentaryFull Text
Lancet Respir Med. 2018 February 5; Volume 6 (Issue 4); DOI:10.1016/S2213-2600(18)30066-3
Hughes J, Snyman L
Lancet Respir Med. 2018 February 5; Volume 6 (Issue 4); DOI:10.1016/S2213-2600(18)30066-3
Journal Article > ReviewFull Text
Int J Tuberc Lung Dis. 2020 May 1; Volume 24 (Issue 5); DOI:10.5588/ijtld.18.0240
Harding R, Snyman L, Ostgathe C, Odell S, Gwyther L
Int J Tuberc Lung Dis. 2020 May 1; Volume 24 (Issue 5); DOI:10.5588/ijtld.18.0240
Patients diagnosed with tuberculosis (TB) continue to
experience clinical uncertainty and high mortality and to
bear a high burden of symptoms and other concerns.
Additional concerns may be family support needs and
stigma, particularly the latter, as TB and human
immunodeficiency virus (HIV) coinfection are common.
Human rights covenants, global health policy and the
End TB Strategy all recommend palliative care as an
essential component of care services. As established in
the resolution adopted by the World Health Assembly
(WHA) on ‘‘Strengthening of palliative care as a
component of comprehensive care throughout the life
course’’, there is a ‘‘need for palliative care across disease
groups (non-communicable diseases, and infectious
diseases, including HIV and multidrug-resistant tuberculosis), and across all age groups’’. We address the
ethical imperative to respect the dignity and fundamental rights of people with TB by providing palliative care.
We review the evidence for the need for person-centred
palliative care and highlight novel models that utilise the
skills and training functions of specialist palliative care
to achieve better care. We outline simple recommendations for the delivery of specialist and generalist
palliative care, offer suggestions on how to ensure
optimal coverage by enabling access to appropriate
good-quality palliative care at all points of the health
system, including alongside treatment. Finally, we set
out the current priorities for research and policy to
ensure that quality care is delivered to all who need it
irrespective of treatment outcome, to minimise distress
and to optimise engagement in treatment and care.
experience clinical uncertainty and high mortality and to
bear a high burden of symptoms and other concerns.
Additional concerns may be family support needs and
stigma, particularly the latter, as TB and human
immunodeficiency virus (HIV) coinfection are common.
Human rights covenants, global health policy and the
End TB Strategy all recommend palliative care as an
essential component of care services. As established in
the resolution adopted by the World Health Assembly
(WHA) on ‘‘Strengthening of palliative care as a
component of comprehensive care throughout the life
course’’, there is a ‘‘need for palliative care across disease
groups (non-communicable diseases, and infectious
diseases, including HIV and multidrug-resistant tuberculosis), and across all age groups’’. We address the
ethical imperative to respect the dignity and fundamental rights of people with TB by providing palliative care.
We review the evidence for the need for person-centred
palliative care and highlight novel models that utilise the
skills and training functions of specialist palliative care
to achieve better care. We outline simple recommendations for the delivery of specialist and generalist
palliative care, offer suggestions on how to ensure
optimal coverage by enabling access to appropriate
good-quality palliative care at all points of the health
system, including alongside treatment. Finally, we set
out the current priorities for research and policy to
ensure that quality care is delivered to all who need it
irrespective of treatment outcome, to minimise distress
and to optimise engagement in treatment and care.
Journal Article > ResearchFull Text
Arch Pediatr Infect Dis. 2014 July 21; Volume 2 (Issue 2); 1-6.; DOI:10.5812/pedinfect.17934
Moyo S, Furin J, Hughes J, Daniels J, Snyman L, et al.
Arch Pediatr Infect Dis. 2014 July 21; Volume 2 (Issue 2); 1-6.; DOI:10.5812/pedinfect.17934
BACKGROUND
There is limited data on outcomes of adolescents with drug-resistant tuberculosis (DR-TB). Objectives: To describe patient outcomes and factors associated with outcomes of adolescents diagnosed with DR-TB in Khayelitsha, South Africa.
PATIENTS AND METHODS
A retrospective analysis of data for adolescents aged 10-19 years who were diagnosed with DR-TB between January 2008 and August 2013 was conducted. The proportions of adolescents with treatment success (cure and treatment completion), failure of treatment, those lost from treatment, and those who died were calculated and compared by HIV status. Proportions and odd ratios are presented.
RESULTS
Seventy-one adolescents were diagnosed with DR-TB. Six (8%) were lost to care before treatment could be initiated. The median age of those started on treatment was 18 years (IQR 15.8-18.9). Eighteen (27.7%) were HIV infected. Of the 44 adolescents with final treatment outcomes, 36.4% (n=16) were successfully treated, 9.1% (n=4) died, 11.4% (n=9) failed treatment and 43.2% (n=19) were lost from treatment (treatment interrupted for³2 consecutive months). Three of the four patients who died, died within two months of starting therapy. Loss from treatment, and treatment success (cure or treatment completion) did not differ between HIV infected and un-infected adolescents, OR: 2.0, (95% CI 0.56-7.50), P=0.27, and OR: 1.2 (95% CI 0.37-4.43), P=0.71, respectively. All five patients who failed treatment and one of those lost from treatment subsequently died. Overall mortality was 12.1/100 person years.
CONCLUSIONS
HIV infected and uninfected adolescents with DR-TB experienced poor outcomes with high proportions of mortality, treatment failure and loss from treatment. Mortality occurred early in the treatment period suggesting delayed presentation and/or diagnosis. Innovative and targeted strategies are needed to encourage early presentation and improve adherence to treatment among adolescents.
There is limited data on outcomes of adolescents with drug-resistant tuberculosis (DR-TB). Objectives: To describe patient outcomes and factors associated with outcomes of adolescents diagnosed with DR-TB in Khayelitsha, South Africa.
PATIENTS AND METHODS
A retrospective analysis of data for adolescents aged 10-19 years who were diagnosed with DR-TB between January 2008 and August 2013 was conducted. The proportions of adolescents with treatment success (cure and treatment completion), failure of treatment, those lost from treatment, and those who died were calculated and compared by HIV status. Proportions and odd ratios are presented.
RESULTS
Seventy-one adolescents were diagnosed with DR-TB. Six (8%) were lost to care before treatment could be initiated. The median age of those started on treatment was 18 years (IQR 15.8-18.9). Eighteen (27.7%) were HIV infected. Of the 44 adolescents with final treatment outcomes, 36.4% (n=16) were successfully treated, 9.1% (n=4) died, 11.4% (n=9) failed treatment and 43.2% (n=19) were lost from treatment (treatment interrupted for³2 consecutive months). Three of the four patients who died, died within two months of starting therapy. Loss from treatment, and treatment success (cure or treatment completion) did not differ between HIV infected and un-infected adolescents, OR: 2.0, (95% CI 0.56-7.50), P=0.27, and OR: 1.2 (95% CI 0.37-4.43), P=0.71, respectively. All five patients who failed treatment and one of those lost from treatment subsequently died. Overall mortality was 12.1/100 person years.
CONCLUSIONS
HIV infected and uninfected adolescents with DR-TB experienced poor outcomes with high proportions of mortality, treatment failure and loss from treatment. Mortality occurred early in the treatment period suggesting delayed presentation and/or diagnosis. Innovative and targeted strategies are needed to encourage early presentation and improve adherence to treatment among adolescents.