Gridlock from diagnosis to treatment of multidrug resistant tuberculosis (MDR-TB) in Tanzania: patients’ perspectives from a focus group discussion

Abstract

Background Molecular diagnostics have revolutionized the diagnosis of multidrug resistant tuberculosis (MDR-TB). Yet in Tanzania we found delay in diagnosis with more than 70% of MDR-TB patients having a history of several previous treatment courses for TB signaling prior opportunities for diagnosis. We aimed to explore patients’ viewpoints and experiences with personal and socio-behavioral obstacles from MDR-TB diagnosis to treatment in an attempt to understand these prior findings. Methods The study was conducted in December 2016 with MDR-TB patients admitted at Kibong’oto Infectious Diseases Hospital. A qualitative approach deploying focus group discussions (FGDs) was used to gather information. Groups were sex aggregated to allow free interaction and to gauge gender specific issues in the social and behavioral contexts. The FGDs explored pathways and factors in the service delivery that may have contributed in the delay in accessing MDR-TB diagnostics and/or treatment. Collected data were coded, categorized and thematically interpreted. Results Forty MDR-TB patients participated in six FGDs. Challenges and barriers contributing to the delay in accessing MDR-TB diagnosis to treatment were as follows: 1) Participants had a different understanding of MDR-TB that led to seeking services outside the conventional health system; 2) Socio-economic adversity made health-seeking behavior difficult and often unproductive; 3) In the health system, challenges included inadequacy of MDR-TB diagnostic centers, lack of knowledge on behalf of health care providers to consider MDR-TB and order appropriate diagnostics; 4) The specimen referral system for early diagnosis of MDR-TB was inefficient. Non-adherence of TB patients to first-line anti-TB drugs prior to MDR-TB diagnosis, given the multitude of barriers discussed, was coupled with both intentional and unintentional non-adherence of health care providers to international standards of TB care. Conclusion Patient-centered strategies bridging communities and the health system are urgently required for optimum MDR-TB control in Tanzania.

Factors affecting time to treatment initiation after diagnosis for multidrug‐resistant/rifampicin‐resistant tuberculosis patients: A mixed‐methods study in Jakarta, Indonesia

“…A study in India found that HCWs were not properly incentivised to work in the area of MDR/RR-TB, considering the difficult working environment and risk of being infected [26]. HCWs in our study also reported difficulty in hiring MDR/RR-TB staff and their perceived need of more training on MDR-TB, which echoes studies in other countries reporting a lack of knowledge in HCWs, even misconduct of HCWs who charge additional fees from patients [27,28]. In addition, our study reveals a lack of coordination mechanisms between the HCWs in the MDR-TB and other departments, further exacerbating the difficulties created by understaffing.…”

Protocol for establishing an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) for integrating care of communicable and non-communicable diseases using tuberculosis and diabetes as a case study

“…Patient and public involvement Development of this protocol was informed by a series of research studies that included one study that examined patients' experience of health services in the health facilities. 8 Findings from the described research objectives will be shared with patients' organisations for further refinement before subsequently contributing in shaping the agenda of effective integration of communicable and NCDs for policy-makers.…”

“…4 This sobering fact has been illuminated in Tanzanian research studies that uncovered a health system gridlock largely contributed by limited resources and skills-training for front-line healthcare providers, and weak linkage to other health services with the subsequent effect of underuse of technologies. [5][6][7][8][9] Likewise, the prevalence of dual communicable and NCD epidemics is increasing, yet communicable clinics are unprepared to deal with dual services. 10 11 For instance, the prevalence of diabetes mellitus (DM) ranged 4%-17% and hypertension ranged 7%-25% in people leaving with HIV attending clinics in Tanzania cities, while, in other settings within Tanzania, the prevalence of DM ranged 4%-5% and hypertension ranged 22%-30%.…”

Implementation of the ‘Removed Injectable modified Short-course regimens for EXpert Multidrug Resistant Tuberculosis’ (RISE study) in Tanzania: a protocol for a mixed-methods process evaluation

“…The later regimens accommodate new anti-TB medicines such as bedaquiline, delamanid or pretomanid and repurposed anti-TB medicines that include clofazimine and linezolid. Various reports in Tanzania have shown multitude of implementation barriers and bottlenecks including limited knowledge of healthcare workforce, delay in diagnosis of RR-TB/MDR-TB, patients receiving multiple episodes of TB treatment and non-difference in final treatment outcomes in patients diagnosed with new technologies 9–11. Without addressing the implementation barriers, new technologies including new drugs might not improve the treatment outcomes and therefore WHO suggested that in resource-limited setting, adapting new second-line anti-TB regimen be implemented under pragmatic research approach 9…”

“…Tanzania is one of the countries that developed a pragmatic protocol and is implementing an injectable-free regimen protocol titled as ‘Removed Injectable modified Short—course regimens for EXpert Multidrug Resistant Tuberculosis’ (RISE study). Key changes in the MDR-TB regimen include substitution of injectable agents with bedaquiline and prioritised levofloxacin and linezolid as described elsewhere 9 10. The RISE study is a prospective open-label cohort continuously enrolling eligible patients (patients with newly diagnosed pulmonary MDR-TB) measuring uptake (enrolment), 6-month conversion, serious adverse events treatment results at 9 months (primary end point) and relapse and death during a follow-up period of 12 months (secondary end point).…”