Treatment Adherence Among Persons Receiving Concurrent MDR TB and HIV Treatment in KwaZulu-Natal, South Africa 公开

Stephens, Fay Katharine (2017)

Permanent URL: https://etd.library.emory.edu/concern/etds/mg74qm405?locale=zh
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Abstract

Background

Concurrent multidrug-resistant tuberculosis (MDR-TB) and human immunodeficiency virus (HIV) treatment entails high pill burden, frequent adverse events and long therapy duration. KwaZulu-Natal province, South Africa, has approximately 5,000 MDR-TB cases annually (80% HIV-infected). We evaluated adherence to MDR-TB and antiretroviral therapy (ART) and its association with treatment outcomes.

Methods

We prospectively followed MDR-TB patients for 24 months. Adherence was assessed monthly using 3-day recall, 30-day recall and visual analog scale (VAS). MDR-TB treatment success was defined as cure or completion; failure, death or loss-to-follow-up were unsuccessful outcomes. We determined the proportion of fully adherent participants by each adherence measure, stratified by HIV status. We assessed the association with MDR-TB treatment success and 60-day culture conversion using unadjusted risk ratios. Among HIV-positive participants, we examined differential adherence to MDR-TB vs. HIV treatment using McNemar's test.

Results

Among 200 MDR-TB patients, 63% were female, median age was 33 years, and 144 (72%) were HIV-positive, of whom 81% were receiving ART at baseline. Adherence to MDR-TB and HIV treatment was high across all measures (82-96% fully adherent) and did not differ by HIV status (Figure). Among HIV-positive participants, ART adherence was significantly higher than MDR-TB treatment adherence by all measures (Figure). Using a composite measure of 3-day recall and VAS, MDR-TB treatment success and 60-day culture conversion were higher among participants who were fully adherent, but this difference was not statistically significant (RR: 1.11, 95%CI: 0.87-1.41; RR: 1.29, 95% CI: 0.70-2.43).

Conclusions

Self-reported MDR-TB treatment adherence was high and did not differ by HIV status, suggesting co-treated persons can achieve high adherence. Reported adherence to ART was higher than to MDR-TB treatment by all study measures. More objective adherence measures and a better understanding of preferential ART adherence are needed to inform interventions that improve outcomes for MDR-TB and HIV co-infected persons.

Table of Contents

Table of Contents

CHAPTER I: LITERATURE REVIEW ....... 1

Global TB and HIV Epidemics ....... 1

Multidrug-Resistant Tuberculosis ....... 1

MDR TB and HIV Co-infection. ....... 3

Prevalence. .......3

Treatment and Treatment Outcomes .......3

Context of MDR TB and HIV in South Africa. .......5

Adherence to Drug-Susceptible TB Treatment ....... 7

Measuring Adherence to TB Treatment .......8

The Evolving Role of DOT . ....... 8

Challenges to TB Treatment Adherence . ....... 10

Gaps in Knowledge . ....... 11

Adherence to MDR TB Treatment .......12

Measuring Adherence to MDR TB Treatment ....... 12

Barriers to Adherence to MDR TB Treatment .......14

What is known in MDR TB Treatment Adherence. .......15

Gaps in Knowledge. .......15

HIV Treatment Adherence. .......16

Measuring Adherence to ART. .......17

Gaps and Challenges to ART Adherence Measurement ....... 19

TB/HIV Co-Infection Adherence. ....... 20

MDR-TB/HIV Co-Treatment Adherence. .......21

Importance of and Measurements for Adherence to Treatment .......21

Challenges to Adherence in the Context of MDR TB/HIV. .......22

Gaps in Knowledge. .......23

Self-Report Adherence Measures .......24

Adherence Measures in Other Diseases .......25

Four Self-Report Adherence Measures in TB Treatment ....... 27

Conclusion. .......29

CHAPTER II: MANUSCRIPT. .......31

ABSTRACT. .......31

INTRODUCTION.. .......32

METHODS. .......34

Study Design and Population . ....... 34

Adherence measurement .......35

Outcomes of interest .......36

Data Analysis .......36

Ethical Considerations .......37

RESULTS. .......37

DISCUSSION.. .......40

REFERENCES. .......44

TABLES. ....... 51

Table 1. Baseline characteristics of the SHOUT cohort (N=200). ....... 51

Table 2. Proportion of participants fully adherenta to MDR TB and HIV medication using three adherence measures, by HIV status. ....... 52

Table 3. Relative risk of successful MDR TB and HIV treatment outcome among fully adherenta participants. .......53

FIGURES. ....... 54

Figure 1. Enrollment flowchart of participants screened and enrolled. ....... 54

Figure 2. Proportion of MDR TB/HIV-positive participants fully adherent to MDR TB and HIV treatment regimens, by adherence measure (n=139). ....... 55

CHAPTER III: PUBLIC HEALTH IMPLICATIONS AND FUTURE DIRECTIONS. ....... 56

Table A1. Performance of adherence measures for predicting MDR TB and HIV treatment outcomes in the SHOUT cohort. ....... 59

APPENDIX A: ADDITIONAL TABLES. .......59

Table A2a. Baseline demographic characteristics of the SHOUT cohort, by adherencea status throughout the study (N=200). .......61

Table A2b. Baseline medical history and symptoms characteristics of the SHOUT cohort, by adherencea status (N=200). ....... 62

Table A2c. Baseline HIV characteristics of the HIV positive SHOUT cohort, by adherencea status. ....... 63

Table A3a. Baseline demographic characteristics of the SHOUT cohort, by MDR TB treatment outcome (N=200). ....... 64

Table A3b. Baseline medical history and symptoms characteristics of the SHOUT cohort, by MDR TB treatment outcome (N=200) . ....... 65

Table A3c. Baseline HIV characteristics of the HIV positive SHOUT cohort, by MDR TB treatment outcome. ....... 66

APPENDIX B: SELECTED EXAMPLE SAS CODE. ....... 67

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