Pathways to multidrug-resistant tuberculosis diagnosis and treatment initiation: a qualitative comparison of patients’ experiences in the era of rapid molecular diagnostic tests

Abstract

BackgroundAlthough new molecular diagnostic tests such as GenoType MTBDRplus and Xpert® MTB/RIF have reduced multidrug-resistant tuberculosis (MDR-TB) treatment initiation times, patients’ experiences of diagnosis and treatment initiation are not known. This study aimed to explore and compare MDR-TB patients’ experiences of their diagnostic and treatment initiation pathway in GenoType MTBDRplus and Xpert® MTB/RIF-based diagnostic algorithms.MethodsThe study was undertaken in Cape Town, South Africa where primary health-care services provided free TB diagnosis and treatment. A smear, culture and GenoType MTBDRplus diagnostic algorithm was used in 2010, with Xpert® MTB/RIF phased in from 2011–2013. Participants diagnosed in each algorithm at four facilities were purposively sampled, stratifying by age, gender and MDR-TB risk profiles. We conducted in-depth qualitative interviews using a semi-structured interview guide. Through constant comparative analysis we induced common and divergent themes related to symptom recognition, health-care access, testing for MDR-TB and treatment initiation within and between groups. Data were triangulated with clinical information and health visit data from a structured questionnaire.ResultsWe identified both enablers and barriers to early MDR-TB diagnosis and treatment. Half the patients had previously been treated for TB; most recognised recurring symptoms and reported early health-seeking. Those who attributed symptoms to other causes delayed health-seeking. Perceptions of poor public sector services were prevalent and may have contributed both to deferred health-seeking and to patient’s use of the private sector, contributing to delays. However, once on treatment, most patients expressed satisfaction with public sector care. Two patients in the Xpert® MTB/RIF-based algorithm exemplified its potential to reduce delays, commencing MDR-TB treatment within a week of their first health contact. However, most patients in both algorithms experienced substantial delays. Avoidable health system delays resulted from providers not testing for TB at initial health contact, non-adherence to testing algorithms, results not being available and failure to promptly recall patients with positive results.ConclusionWhilst the introduction of rapid tests such as Xpert® MTB/RIF can expedite MDR-TB diagnosis and treatment initiation, the full benefits are unlikely to be realised without reducing delays in health-seeking and addressing the structural barriers present in the health-care system.

Gridlock from Diagnosis to Treatment of Multidrug Resistant Tuberculosis (MDR-TB) in Tanzania: Patients’ Perspectives from the Focus Group Discussion

“…Likely more important is that the health system lacks efficient mechanisms for onsite specimen testing or referral of specimens and relaying of results, a common phenomenon occuring in many developing countries [13], but one in which if ameliorated would concurrently raise awareness and testing for MDR-TB among the HCW. Lack of efficient mechanisms for specimen refferals was shown to contribute substantial delay in MDR-TB diagnosis to treatment similar to what other settings reports within and outside of sub-Saharan Africa [14,15]. Importantly, participants described corruption as a major barrier and their accounts were vividly detailed inclduign health care providers asking for informal payment from patients for anti-TB refill and TB diagnostic tests.…”

Rifampicin resistant tuberculosis in presumptive pulmonary tuberculosis cases in Dubti Hospital, Afar, Ethiopia

“…Gram stains on sputum specimen were done to assure quality based on the numbers of polymorph nuclear leukocytes and squamous epithelial cells present. Sputum with polymorph nuclear leucocytes > 10/ low power field and squamous epithelial cells < 25/low power field per 10 fields was considered as good quality [21].…”

“…TB case-finding strategies for RIF resistant TB cases in Ethiopia focus on previously treated TB patients and the following groups of patients (HIV positive persons, contacts of patients with MDR-TB cases, refugees, prisoners and persons aged less than 15 years) [1,14,21,22]. Therefore, the present study was designed to assess the prevalence and assess the risk factors for RIF resistant TB at Dubti general hospital, Afar, north Ethiopia.…”

Diagnosis and treatment of TB patients with rifampicin resistance detected using Xpert® MTB/RIF in Zimbabwe

“…26 Possible reasons for delays in starting treatment in Zimbabwe might be the time taken in conducting the baseline biochemistry tests on liver and renal function and the decision to start MDR-TB treatment, which is made by the clinical management team. Previous studies conducted elsewhere have shown that delayed treatment is due to a combination of patient and health system factors, [27][28][29] and these need to be addressed.…”