Beyond pills and tests: addressing the social determinants of tuberculosis

Abstract

Poverty drives tuberculosis (TB) rates but the approach to TB control has been disproportionately biomedical. In 2015, the World Health Organization's End TB Strategy explicitly identified the need to address the social determinants of TB through socio-economic interventions. However, evidence concerning poverty reduction and cost mitigation strategies is limited. The research described in this article, based on the 2016 Royal College of Physicians Linacre Lecture, aimed to address this knowledge gap. The research was divided into two phases: the first phase was an analysis of a cohort study identifying TB-related costs of TB-affected households and creating a clinically relevant threshold above which those costs became catastrophic; the second was the design, implementation and evaluation of a household randomised controlled evaluation of socio-economic support to improve access to preventive therapy, increase TB cure, and mitigate the effects of catastrophic costs. The first phase showed TB remains a disease of people living in poverty - 'free' TB care was unaffordable for impoverished TB-affected households and incurring catastrophic costs was associated with as many adverse TB treatment outcomes (including death, failure of treatment, lost to follow-up and TB recurrence) as multidrug resistant (MDR) TB. The second phase showed that, in TB-affected households receiving socio-economic support, household contacts were more likely to start and adhere to TB preventive therapy, TB patients were more likely to be cured and households were less likely to incur catastrophic costs. In impoverished Peruvian shantytowns, poverty remains inextricably linked with TB and incurring catastrophic costs predicted adverse TB treatment outcome. A novel socio-economic support intervention increased TB preventive therapy uptake, improved TB treatment success and reduced catastrophic costs. The impact of the intervention on TB control is currently being evaluated by the Community Randomized Evaluation of a Socio-economic Intervention to Prevent TB (CRESIPT) study.

Delays to treatment initiation is associated with tuberculosis treatment outcomes among patients on directly observed treatment short course in Southwest Ethiopia: a follow-up study

“…In the current study, the majority (84.7%) of the cases had visited an average of 2.2 HCFs until diagnosis of TB at which time both self and prescribed medicines had been used. Third, delays to treatment often accompanied by higher direct and indirect costs that impoverish households [ 36 , 37 ] and ultimately lead to poor treatment compliance and outcome [ 36 ]. In our study we observed significantly higher median pre diagnosis (US$119.1 vs 48.2, p = 0.001)and post diagnosis (US$93.7vs.98.8, p < 0.001) costs among those delayed to initiate treatment which could explain the increased risk of unsuccessful outcome.…”

Cash transfer scheme for people with tuberculosis treated by the National TB Programme in Western India: a mixed methods study

“…The average expenditure incurred by patients in low-income and middle-income countries towards diagnosis and treatment of TB ranges from $55 to $8198,1 placing their households at higher risk of catastrophic costs due to TB care 2–6. Catastrophic costs create access and adherence barriers, which, in turn, are associated with adverse TB treatment outcomes including death, failure of treatment, loss to follow-up, recurrence and multidrug-resistant (MDR) TB 7…”

Tuberculosis en el Perú: Situación epidemiológica, avances y desafíos para su control

“…La tuberculosis (TB) es una enfermedad infectocontagiosa, prevenible, curable y con un importante componente social (1) . Según estimaciones de la Organización Mundial de la Salud (OMS), la incidencia anual de la TB a nivel mundial está disminuyendo lentamente, alrededor de 1,5% desde el año 2000; sin embargo, el número absoluto de casos de TB se viene incrementando.…”