Effect of a Nurse-Led Community Health Worker Intervention on Latent Tuberculosis Medication Completion Among Homeless Adults

Abstract

Background: Tuberculosis (TB) disproportionately affects marginalized and impoverished homeless adults. Although active TB can be prevented by treating latent TB infection (LTBI), individual factors, such as high prevalence of depression and anxiety, drug and alcohol use, and unstable housing, lead to poor LTBI treatment adherence and completion among homeless adults.Objectives: We hypothesized that the delivery of a tailored nurse-led, community health worker (RN/CHW) program across the LTBI continuum of care (e.g., screening, diagnosis, and treatment) that delivers 3HP treatment (3HP: rifapentine plus isoniazid) for homeless adults (e.g., sheltered and unsheltered) and is tailored to their health and social service needs will overcome existing treatment completion barriers. We also hypothesized that mental health symptoms (e.g., depression and anxiety), drug use score, and problematic alcohol use will decline over time among clients receiving this treatment. Methods:We assessed the effect of delivering a theoretically guided, RN/CHW-based, single-arm study among eligible LTBIpositive homeless adults (N = 50) on completion of a weekly, directly observed, 12-dose 3HP LTBI treatment in Central City East (Skid Row). Completing 3HP treatment was compared to the only known historical, clinic-based control that obtained 65% completion among homeless adults. Secondary outcomes included drug and alcohol use, depression, and anxiety. Results:The RN/CHW program achieved a 91.8% 3HP treatment completion rate among homeless adults. Younger homeless adults (<50 years old) were less likely to complete 3HP treatment compared to those who were older. Neither drug use, depression, nor anxiety was associated with 3HP treatment completion. Decrease in anxiety was observed at 3 months, but not at 6 months, compared to baseline.Discussion: To our knowledge, the pilot study is the first to evaluate an effective RN/CHW-delivered, community-based intervention, which can reduce the burden of active TB for homeless adults.

Nurse‐led intervention to decrease drug use among LTBI positive homeless adults

“…This paper is based on a single-arm study, in which we assessed the impact of a novel intervention, wherein homeless adults who were found to be LTBI positive, and met eligibility criteria, were subsequently offered a 12-dose (i.e., 3HP; rifapentine plus isoniazid) weekly treatment by our Registered Nurse-Community Health Worker (RN-CHW) team. Our findings were promising in that among LTBI positive PEH, a 92% 3HP completion rate was achieved, regardless of drug use, anxiety, or depression (Nyamathi et al, 2021), as compared to a 65% clinic based, historical control (Chang, 2016).…”

“It’s too hard” – the management of latent TB in under-served populations in the UK: a qualitative study

“…With this lens, we feel that whilst risks of treatment were perceived by participants as higher in under-served populations, the real issue is the inability of current care models to adequately mitigate against them. High completion rates of LTBI treatment have been successfully achieved in community-based approaches both in homeless [20] and incarcerated populations [21].…”

“…It was notable that there were very few comments about potential practical solutions to service level challenges despite these topics being included in the topic guide. These include the use of rifapentine-based regimens, shown to improve outcomes in under-served populations [20,24,30], novel diagnostics such as c-TB, which may remove some practical challenges such as venepuncture [31], use of peer support / outreach workers [32,33], and video-observed-treatment (VOT) [34,35]. Workforce training to ensure optimal use of evidence-based strategies may help target some of these short-comings.…”

“It’s too hard” – the management of latent TB in under-served populations in the UK: a qualitative study

“…It was notable that there were very few comments about potential practical solutions to service level challenges despite these topics being included in the topic guide. These include the use of rifapentinebased regimens, shown to improve outcomes in under-served populations 21,27,28 , novel diagnostics such as c-TB, which may remove some practical challenges such as venepuncture 29 , and the use of peer support workers 30,31 . Workforce training to ensure optimal use of evidence-based strategies may help target some of these short-comings.…”