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

PLoS One. 2020 Dec 29;15(12):e0244451. doi: 10.1371/journal.pone.0244451. eCollection 2020.

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Worldwide, Drug-resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the clinical management capacity thereby causing ethical challenges.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.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aftercare / organization & administration
  • Aftercare / statistics & numerical data
  • Anti-Retroviral Agents / therapeutic use
  • Antitubercular Agents / pharmacology
  • Antitubercular Agents / therapeutic use
  • Chemoprevention / methods
  • Cohort Studies
  • Coinfection / drug therapy*
  • Coinfection / microbiology
  • Delivery of Health Care / methods
  • Delivery of Health Care / organization & administration*
  • Delivery of Health Care / statistics & numerical data
  • Drug Resistance, Multiple, Bacterial
  • Female
  • HIV Infections / drug therapy*
  • HIV Infections / virology
  • Health Plan Implementation*
  • Humans
  • Leprosy / drug therapy*
  • Leprosy / microbiology
  • Male
  • Middle Aged
  • Models, Organizational
  • Mycobacterium leprae / isolation & purification
  • Mycobacterium tuberculosis / isolation & purification
  • Patient Care Team / organization & administration
  • Patient Care Team / statistics & numerical data
  • Treatment Outcome
  • Trimethoprim, Sulfamethoxazole Drug Combination / therapeutic use
  • Tuberculosis, Multidrug-Resistant / drug therapy*
  • Tuberculosis, Multidrug-Resistant / microbiology
  • Uganda
  • Young Adult

Substances

  • Anti-Retroviral Agents
  • Antitubercular Agents
  • Trimethoprim, Sulfamethoxazole Drug Combination