Evaluation of adherence to national treatment guidelines among tuberculosis patients in three provinces of South Africa

Abstract

Background Standardised tuberculosis (TB) treatment through directly observed therapy (DOT) is available in South Africa, but the level of adherence to standardised TB treatment and its impact on treatment outcomes is unknown. Objectives To describe adherence to standardised TB treatment and provision of DOT, and analyse its impact on treatment outcome. Methods We utilised data collected for an evaluation of the South African national TB surveillance system. A treatment regimen was considered appropriate if based on national treatment guidelines. Multivariate log-binomial regression was used to evaluate the association between treatment regimens, including DOT provision, and treatment outcome. Results Of 1 339 TB cases in the parent evaluation, 598 (44.7%) were excluded from analysis owing to missing outcome or treatment information. The majority (697, 94.1%) of the remaining 741 patients received an appropriate TB regimen. Almost all patients (717, 96.8%) received DOT, 443 (59.8%) throughout the treatment course and 274 (37.0%) during the intensive (256, 34.6%) or continuation (18, 2.4%) phase. Independent predictors of poor outcome were partial DOT (adjusted risk ratio (aRR) 3.1, 95% confidence interval (CI) 2.2 – 4.3) and previous treatment default (aRR 2.3, 95% CI 1.1 – 4.8). Conclusion Patients who received incomplete DOT or had a history of defaulting from TB treatment had an increased risk of poor outcomes.

The costs and outcomes of paediatric tuberculosis treatment at primary healthcare clinics in Johannesburg, South Africa

“…We also determined that one-third of prescribed regimens in our study (33%, 29/88) did not appear to follow national treatment guidelines. While lower rates of inappropriate regimens in children <8 years of age (11%) have been reported in other studies from SA, [7] the use of inappropriate regimens is known to be a relatively widespread problem [26] and can contribute to both treatment failure and the development of drug resistance. [27] A systematic review has found that inadequate knowledge of national treatment guidelines among healthcare workers is also relatively common, although the review did not include any literature from SA.…”

“…[25] A small cohort drawn from three provinces in 2009 showed slightly higher rates of treatment success (88%, 65/74) in children <8 years of age. [7] A record review of children (aged 0 -15 years) living in periurban communities found that treatment success was good (79%, 65/82 in 2008 -2011) among patients receiving supervised home visits from trained community caregivers or nurses, but clinic-based treatment showed relatively low rates of success (54%, 52/97 in 2005 -2008) and high rates of loss to follow-up (38%). [8] In comparison, older studies (2003 -2005) of hospital-based treatment in Cape Town reported treatment success of 71% (97/137) in HIV-infected children (aged 0 -11 years), [9] and higher mortality in young children (9%, 31/334, age <3 years) than older children (4%, 10/262, age 4 -13 years), although treatment outcomes were not reported separately from patients who tested positive for drug resistance (11%).…”

‘They are inconveniencing us’ - exploring how gaps in patient education and patient centred approaches interfere with TB treatment adherence: perspectives from patients and clinicians in the Free State Province, South Africa

“…Health education is integrated into services provided at primary health care (PHC) level in South Africa [15]. However, inadequate patient counselling on treatment expectations [16,17] and inconsistent implementation of the Directly Observed Treatment, Short Course (DOTS) strategy [18,19] continue to exacerbate TB treatment LTFU. Apart from South Africa, similar findings of poor patientprovider communication hindering TB treatment completion have been demonstrated as far afield as Eritrea, Tanzania, Pakistan and Ethiopia; always with the discussion prioritizing strengthened patient-provider trust and treatment literacy [20][21][22][23][24].…”

Outcomes of treatment of drug-susceptible tuberculosis at public sector primary healthcare clinics in Johannesburg, South Africa: A retrospective cohort study

“…Data from Gauteng, KwaZulu-Natal and Mpumalanga provinces in 2009 indicated that while nearly all patients (97%) received DOT support through the intensive phase of treatment, only 60% of patients received DOT support throughout the full treatment course. [6] Objective To contribute to the evidence base on public sector TB treatment service delivery, we constructed a retrospective cohort of adult TB patients treated at three public sector clinics in the city of Johannesburg. Using medical record data, we report patient characteristics, HIV status and TB history, diagnosis and laboratory information, treatment characteristics, DOT supervision and treatment outcomes for this cohort.…”