Jennifer R Zelnick1, Amrita Daftary2,3, Christina Hwang4, Amy S Labar5, Resha Boodhram3, Bhavna Maharaj3, Allison K Wolf6, Shinjini Mondal7, K Rivet Amico8, Catherine Orrell9, Boitumelo Seepamore10, Gerald Friedland11, Nesri Padayatchi3, Max R O'Donnell3,4,6. 1. Graduate School of Social Work, Touro College and University System, New York, New York, USA. 2. Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Canada. 3. Center for the AIDS Programme of Research in South Africa, Medical Research Council HIV-TB Pathogenesis and Treatment Research Unit (CAPRISA MRC-HIV-TB), Durban, South Africa. 4. Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, New York, USA. 5. Vagelos College of Physician and Surgeons, Columbia University, New York, New York, USA. 6. Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York, USA. 7. Department of Family Medicine, McGill University, Montreal, Canada. 8. University of Michigan School of Public Health, Ann Arbor, Michigan, USA. 9. Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa. 10. University of Kwazulu-Natal, Durban, South Africa. 11. Yale School of Medicine, New Haven, Connecticut, USA.
Abstract
BACKGROUND: In generalized drug-resistant tuberculosis (DR-TB) human immunodeficiency virus (HIV) epidemics, identifying subpopulations at high risk for treatment failure and loss to care is critically important to improve treatment outcomes and prevent amplification of drug resistance. We hypothesized that an electronic dose-monitoring (EDM) device could empirically identify adherence-challenged patients and that a mixed-methods approach would characterize treatment challenges. METHODS: A prospective study of patients with DR-TB HIV on antiretroviral therapy (ART) initiating bedaquiline-containing regimens in KwaZulu-Natal, South Africa. Separate EDM devices measured adherence for bedaquiline and ART. Patients with low adherence (<85%) to both bedaquiline and ART were identified as high risk for poor outcomes. Baseline survey, study visit notes, and focus group discussions characterized treatment challenges. RESULTS: From December 2016-February 2018, 32 of 198 (16%) enrolled patients with DR-TB HIV were identified as dual-adherence challenged. In a multivariate model including baseline characteristics, only receiving a disability grant was significantly associated with dual nonadherence at 6 months. Mixed-methods identified treatment barriers including alcohol abuse, family conflicts, and mental health issues. Compared with adherent patients, dual-adherence-challenged patients struggled to prioritize treatment and lacked support, and dual-adherence-challenged patients experienced higher rates of detectable HIV viral load and mortality than more adherent patients. CONCLUSIONS: EDM empirically identified a subpopulation of patients with DR-TB HIV with dual-adherence challenges early in treatment. Mixed-methods revealed intense psychosocial, behavioral, and structural barriers to care in this subpopulation. Our data support developing differential, patient-centered, adherence support interventions focused on psychosocial and structural challenges for subpopulations of at-risk DR-TB HIV patients.
BACKGROUND: In generalized drug-resistant tuberculosis (DR-TB) human immunodeficiency virus (HIV) epidemics, identifying subpopulations at high risk for treatment failure and loss to care is critically important to improve treatment outcomes and prevent amplification of drug resistance. We hypothesized that an electronic dose-monitoring (EDM) device could empirically identify adherence-challenged patients and that a mixed-methods approach would characterize treatment challenges. METHODS: A prospective study of patients with DR-TB HIV on antiretroviral therapy (ART) initiating bedaquiline-containing regimens in KwaZulu-Natal, South Africa. Separate EDM devices measured adherence for bedaquiline and ART. Patients with low adherence (<85%) to both bedaquiline and ART were identified as high risk for poor outcomes. Baseline survey, study visit notes, and focus group discussions characterized treatment challenges. RESULTS: From December 2016-February 2018, 32 of 198 (16%) enrolled patients with DR-TB HIV were identified as dual-adherence challenged. In a multivariate model including baseline characteristics, only receiving a disability grant was significantly associated with dual nonadherence at 6 months. Mixed-methods identified treatment barriers including alcohol abuse, family conflicts, and mental health issues. Compared with adherent patients, dual-adherence-challenged patients struggled to prioritize treatment and lacked support, and dual-adherence-challenged patients experienced higher rates of detectable HIV viral load and mortality than more adherent patients. CONCLUSIONS: EDM empirically identified a subpopulation of patients with DR-TB HIV with dual-adherence challenges early in treatment. Mixed-methods revealed intense psychosocial, behavioral, and structural barriers to care in this subpopulation. Our data support developing differential, patient-centered, adherence support interventions focused on psychosocial and structural challenges for subpopulations of at-risk DR-TB HIV patients.
Authors: M R O'Donnell; A Daftary; M Frick; Y Hirsch-Moverman; K R Amico; M Senthilingam; A Wolf; J Z Metcalfe; P Isaakidis; J L Davis; J R Zelnick; J C M Brust; N Naidu; M Garretson; D R Bangsberg; N Padayatchi; G Friedland Journal: Int J Tuberc Lung Dis Date: 2016-04 Impact factor: 2.373
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