TB treatment delays and associated risk factors in Dushanbe, Tajikistan, 2019–2021

Abstract

Background In Tajikistan, where there are about 8,000 cases annually, many new cases are being diagnosed with severe disease, indicating a delay in receiving care. We aimed to estimate the proportion with delayed care and the main factors contributing to delayed care. Methods Using a retrospective cohort design, we conducted a study that included all people aged over 15 years who were newly diagnosed with pulmonary TB in Dushanbe from 2019 to 2021. We defined ‘patient delay’ as > 14 days from TB symptom onset to the first provider visit and ‘provider delay’ as > 3 days from the first visit to treatment initiation. Data was abstracted from medical records and participants were interviewed in-person. Multivariable negative binomial regression was used to estimate adjusted risk ratios (aRR) and 95% confidence intervals (CI). Results Of 472 participants, 49% were male, 65% had lung tissue cavitation, 33% had drug resistant TB, 11% had diabetes, 4% had HIV, and. Reported cases dropped from 196 in 2019 to 109 in 2020 and increased to 167 in 2021. The proportion of people experiencing patient delays was 82%, 72%, and 90% per year, respectively. The proportion of provider delays was 44%, 41% and 29% per year. Patient delay was associated with year (aRR: 1.09 [CI:1.02–1.18] in 2021 vs. 2019), age (aRR:0.91 [0.82–0.99] for 40–59-year-olds vs. 15–39-year-olds), having HIV (aRR:1.22 [1.08–1.38]), having blood in sputum (aRR:1.19 [1.10–1.28]), chest pain (aRR:1.32 [1.14–1.54]), having at least two structural barriers vs. none (aRR:1.52 [1.28–1.80]), having one of the following barriers: long wait lines (aRR:1.36 [1.03–1.80]), feeling that healthcare services were expensive (aRR:1.54 [1.28–1.85]), or having no time or too much work (aRR:1.54 [1.29–1.84]). Provider delay was associated with year (aRR: 0.67 [0.51–0.89] in 2021 vs. 2019), patients having to pay for X-ray services (aRR: 1.59 [1.22–2.07]) and lacking direct-observed-therapy (DOTS) in facility (aRR: 1.61 [1.03–2.52]). Conclusions Patient delay was high before the COVID-19 pandemic and increased in 2021, while provider delay decreased during this time. Addressing structural barriers to healthcare services, such as increased DOTS facilities, expanded hours, and zero fees, may decrease delays.