Although 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.
The 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.
We 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.
Whilst 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.
Below: Testing in the LPA and
Xpert-based TB diagnostic algorithms. High MDR-TB-risk presumptive cases refer
to those with previous TB, an MDR-TB contact or from a congregate setting. In
the LPA-based algorithm, only these cases were initially screened for drug susceptibility.
Low MDR-risk presumptive TB cases would only be identified when 1 st -line TB treatment regimens failed. In the Xpert-based
algorithm in comparsion, all presumptive TB cases were simultaneously screened
for TB and rifampicn resistance using Xpert
Full article
at:
1Desmond Tutu TB Centre, Department of
Paediatrics and Child Health, Faculty of Medicine and Health Sciences,
Stellenbosch University, Stellenbosch, South Africa
2Health Systems Research Unit, South African
Medical Research Council, Cape Town, South Africa
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