Addressing the drug-resistant tuberculosis challenge through implementing a mixed model of care in Uganda

Abstract

Worldwide, Drug-resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the clinical management capacity thereby causing ethical challenges. In Sub-Saharan Africa, treatment is either inadequate or lacking and some diagnosed patients are on treatment waiting lists. In Uganda, various health system challenges impeded scale-up of DR-TB care in 2012; only three treatment initiation facilities existed, with only 41 of the estimated 1010 RR-TB/MDR-TB cases enrolled on treatment yet 300 were on the waiting list and there was no DR-TB treatment scale-up plan. To scale up care, the National TB and leprosy Program (NTLP) with partners rolled out a DR-TB mixed model of care. In this paper, we share achievements and outcomes resulting from the implementation of this mixed Model of DR-TB care. Routine NTLP DR-TB program data on treatment initiation site, number of patients enrolled, their demographic characteristics, patient category, disease classification (based on disease site and human immunodeficiency virus (HIV) status), on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART) statuses, culture results, smear results and treatment outcomes (6, 12, and 24 months) from 2012 to 2017 RR-TB/MDR-TB cohorts were collected from all the 15 DR-TB treatment initiation sites and descriptive analysis was done using STATA version 14.2. We presented outcomes as the number of patient backlog cleared, DR-TB initiation sites, RR-TB/DR-TB cumulative patients enrolled, percentage of co-infected patients on the six, twelve interim and 24 months treatment outcomes as per the Uganda NTLP 2016 Programmatic Management of drug-resistant Tuberculosis (PMDT) guidelines (NTLP, 2016). Over the period 2013–2015, the RR-TB/MDR-TB Treatment success rate (TSR) was sustained between 70.1% and 74.1%, a performance that is well above the global TSR average rate of 50%. Additionally, the cure rate increased from 48.8% to 66.8% (P = 0.03). The Uganda DR-TB mixed model of care coupled with early application of continuous improvement approaches, enhanced cohort reviews and use of multi-disciplinary teams allowed for rapid DR-TB program expansion, rapid clearance of patient backlog, attainment of high cumulative enrollment and high treatment success rates. Sustainability of these achievements is needed to further reduce the DR-TB burden in the country. We highly recommend this mixed model of care in settings with similar challenges.

Treatment outcomes of pregnant women with drug-resistant tuberculosis in Uganda: A retrospective review of 18 cases

“…It is worth noting that DRTB treatment success in Uganda was 74% in the 2017 cohort, which was way above the global estimate of 57% (World Health Organization, 2020) and therefore, it is not surprising that pregnant women with DRTB in Uganda also had a higher rate of treatment success. Additionally, while there was a high prevalence of HIV among pregnant women in our study, the proportion is lower than the 53%-59% reported among nationwide DRTB cohorts whose treatment success rate was >70% (Baluku et al, 2021;Kasozi et al, 2020). Even among people with TB/HIV co-infection in Uganda, regardless of pregnancy status, the treatment success rate is 74% (Musaazi et al, 2017).…”

“…Women were monitored monthly for clinical improvement (signs and symptoms), sputum conversion (sputum cultures) and side effects (serum creatinine, liver transaminases, full haemogram and audiometry). Further details of DRTB management in Uganda are described elsewhere (Baluku et al, 2021;Kasozi et al, 2020).…”

“…Uganda is a TB/HIV high-burdened country where 52%-62% patients with DRTB are co-infected with HIV (Baluku et al, 2020;Kasozi et al, 2020;Okethwangu et al, 2019). The cumulative number of patients with DRTB enrolled in care was 1352 by 2017, which averaged 225 patients annually, and the treatment success rate has been consistently >70% (Kasozi et al, 2020). In this study, we report characteristics and treatment outcomes of 18 pregnant women who were managed for DRTB in Uganda between 2013 and 2019.…”

Multidisciplinary management of difficult-to-treat drug resistant tuberculosis: a review of cases presented to the national consilium in Uganda

“…The total number of inquiries and recommendations of the panel were also enumerated. Full details of the primary study measurements and programmatic management of DR-TB in Uganda are provided elsewhere [ 20 , 21 ]. Treatment outcomes were defined according to WHO definitions [ 22 ].…”

Discontinuation of tuberculosis treatment among children in the Kampala Capital City Authority health facilities: a mixed-methods study

“…Several factors are associated with non-adherence and loss to follow-up among TB patients including children in developing countries leading to DTT among children and include among others, long treatment durations, high pill burden, medication-related side-effects, and symptom resolution [ 9 ]. DTT thus remains a major obstacle to efficient TB control in developing countries like Uganda and has the potential to worsen the emergence of multi-drug resistant TB and death [ 10 , 11 ].…”