Impact of Xpert MTB/RIF and decentralized care on linkage to care and drug-resistant tuberculosis treatment outcomes in Johannesburg, South Africa

Abstract

BackgroundIn 2011, South Africa improved its ability to test for rifampicin-resistant TB (RR-TB) by introducing GeneXpert MTB/RIF. At the same time, the South African National TB program adopted a policy decentralized, outpatient treatment for drug resistant (DR-) TB. We aim to analyze the impact of these changes on linkage to care and DR-TB treatment outcomes.MethodsWe retrospectively matched adult patients diagnosed with laboratory-confirmed RR-TB in Johannesburg from 07/2011–06/2012 (early cohort) and 07/2013–06/2014 (late cohort) with records of patients initiating DR-TB treatment at one of the city’s four public sector treatment sites. We determine the proportion of persons diagnosed with RR-TB who initiated DR-TB treatment and report time to treatment initiation (TTI) before and after the implementation of Xpert MTB/RIF roll-out in Johannesburg, South Africa. We conducted a sub-analysis among those who initiated DR-TB treatment at the decentralized outpatient DR-TB centers to determine if delays in treatment initiation have a subsequent impact on treatment outcomes.ResultsFive hundred ninety four patients were enrolled in the early cohort versus 713 in the late cohort. 53.8 and 36.8% of patients were diagnosed with multi-drug resistant TB in the early and late cohorts, respectively. The proportion of RR-TB confirmed cases diagnosed by Xpert MTB/RIF increased from 43.4 to 60.5% between the early and late cohorts, respectively. The proportion who initiated treatment increased from 43.1% (n = 256) to 60.3% (n = 430) in the late cohort. Pre-treatment mortality during the early and the late cohort reduced significantly from 17.5 to 5.8% while lost to follow-up remained high.Although TTI reduced by a median of 19 days, from 33 days (IQR 12–52) in the early cohort to 14 days (IQR 7–31) in the late cohort, this did not translate to improved treatment outcomes and we found no difference in terms of treatment success or on-treatment mortality for those that initiated without delay vs. those that deferred initiation.ConclusionPre-treatment mortality reduced significantly during late Xpert MTB/RIF coverage but there was no significant difference after treatment was initiated. Despite improvements there is still a significant diagnosis and treatment gap for patients diagnosed with RR-TB and improving treatment outcomes remains critical.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3762-x) contains supplementary material, which is available to authorized users.

Ease and equity of access to free DR-TB services in Nigeria- a qualitative analysis of policies, structures and processes

“…Treatment delays were, thus, related more to inadequate community awareness about TB disease and available services, and distrust of the public sector, agreeing with several studies in sub-Saharan Africa (57)(58)(59). Approachability in several SSA countries were hampered by poor provider knowledge and attitudes, poor referral systems and patient tracking, as in our study (58)(59)(60)(61)(62)(63)(64)(65)(66)(67)(68)(69).…”

Treatment outcomes of multi drug resistant and rifampicin resistant Tuberculosis in Zimbabwe: A cohort analysis of patients initiated on treatment during 2010 to 2015

“…reported in similar patient cohorts from South Africa [18,19] and Zambia [20], where the majority of patients were co-infected with HIV. However, the better treatment outcomes in the current study may be due to potential selection bias of excluding patients treated at primary health centres.…”

Rifampicin Resistant Tuberculosis in Lesotho: Diagnosis, Treatment Initiation and Outcomes

“…This compares well with the median delay-time of 13 days (IQR 7-28) and 15 days (IQR 8-23) reported in Johannesburg and in the Eastern Cape in South Africa, respectively. In a Cape Town study, Cox et al found a relatively shorter median time to treatment initiation of eight days [9][10][11][12] . In these studies, time to treatment initiation was measured from sputum submission at the laboratory while we measured it from the availability of a positive Xpert MTB/RIF assay result with rifampicin resistance.…”