Tuberculosis in key populations in Tajikistan - a snapshot in 2017.

INTRODUCTION: WHO End TB Strategy aims at achieving targets of 90% mortality reduction and 80% reduction in tuberculosis (TB) incidence by 2030, recommending better addressing TB and multidrug-resistant TB (MDR-TB) issues in key populations. AIM: The study aimed at having a snapshot of the epidemiological characteristics of the key populations among the new TB patients, registered in Tajikistan during 2017. METHODOLOGY: A cross-sectional study was conducted, using official TB registration data for all new TB case notification in Tajikistan in 2017. RESULTS: The key population included 1,029 (19.8%) patients among all 5,182 new TB cases registered in 2017. The following selected sub-populations were identified: migrant workers - 728 (70.7%), diabetics - 162 (15.7%), HIV-positive - 138 (13.4%), heavy drinkers - 74 (7.2%), drug users - 50 (4.8%), ex-prisoners - 50 (4.8%), and homeless - 9 (0.9%). Among the key population, 307 (29.8%) patients were smear-positive, 145 (14.1%) were drug-sensitive and 116 (11.3%) had MonoDR/MDR-TB. Time to treatment initiation for smear-positive cases was ≤ 5 days for 303 (98.7%) patients. Being a key population was inversely related to gender (female) (OR = 0.25, 95% CI (0.21, 0.29)) and population type (rural) (OR = 0.64, 95% CI (0.55, 0.74)). CONCLUSION: Among the key population the identified overlaps of selected sub-populations would enable more efficiently reaching the certain groups. TB case detection at PHC levels needs to be targeted for improved rates for key population detection. In the key population sub-group of migrant workers' special migration destinations are recommended to be explored and find out possible associations with drug resistance.

Gaps in tuberculosis control in Armenia: How to improve the care system?

INTRODUCTION: Tuberculosis (TB) continues to be a global public health problem. People with weakened immune systems are more vulnerable to TB. It is one of the top 10 causes of death worldwide and is a leading cause of death for people living with HIV (PLWH). The aim of the current study was to perform programmatic data analysis of TB cases treated with the first-line drugs, registered in Armenia for the period of January 2017 - August 2018, and to identify gaps in TB care system in Armenia. METHODOLOGY: A retrospective cohort study using programmatic data from National TB Program. RESULTS: Overall treatment success rate for the period of study was 79%. HIV had impact only on "died" outcome with odds ratio (OR) of 20.9. More than a third (34%) of all HIV-positive patients died during TB treatment and 45% of patients who had non-Armenian citizenship were lost to follow-up during the treatment (OR = 3.3). Treatment duration for the 8% of all cases (mainly with brain or bone localization) was > 9 months and lasted up to 500 days. CONCLUSIONS: Better collaboration and partial integration of TB and HIV services in Armenia is required. The access to care for non-Armenian citizens needs to be improved. The national TB treatment guideline needs to be updated based on scientific evidence. This study demonstrates that continuous analysis of the available data and tailoring of the system is required to address the needs of key populations and achieve universal care coverage.

Shifting from an inpatient to outpatient centered model through transforming the TB financing in ex-Soviet countries.

INTRODUCTION: In former Soviet Union countries, tuberculosis (TB) financing largely relies on a hospital-centered model. The World Health Organization favors transformation to ambulatory treatment since it is cheaper and patient-centered. We explored policy and decision maker's perspectives on: a) enabling factors for transformation in Armenia and b) challenges and ways forward in doing so in Ukraine and Tajikistan. METHODOLOGY: Qualitative study of key informants from government, donors and the national TB program. RESULTS: 52 informants with a mean service record of 20 years were involved. Key enablers in Armenia included collaborative partnership and political will, carefully selecting an adapted financing scheme that avoided financial penalization of hospitals and health workers, and use of operational research. The operational challenges in Ukraine and Tajikistan hovered around the lack of technical capacity and guidance on "how to implement" alternative financing. Shortcomings in strategic planning, uncertainty/fear that existing hospital funding would be cut and reluctance to change were highlighted. Suggested ways forwards to change the current paradigm included country-level technical assistance, capacity building, regional exchanges and operational research. CONCLUSIONS: the perspectives of "those who decide" on transforming TB financing have been highlighted. Taking these perspectives on-board is vital for achieving the end-TB goals.

Quality of care provided to tuberculosis patients in Armenia: How satisfied are the patients?

INTRODUCTION: Adherence to tuberculosis (TB) treatment as an important determinant for the successful cure of patients can be increased by focusing on patient satisfaction. The objective of this study was to evaluate patient satisfaction with TB services, different aspects of patient satisfaction, and demographic, health and treatment characteristics associated with satisfaction. METHODOLOGY: Overall 505 randomly selected TB patients that received treatment during 2014-2015 in Armenia underwent a cross-sectional telephone survey. Patient satisfaction items were selected from the Patient Satisfaction Questionnaire (PSQ-18). The Consultation and Relational Empathy (CARE) and Patient Enablement Instrument (PEI) were also used. Treatment adherence was assessed using the Morisky Adherence Scale. RESULTS: The respondents comprised 386 (76.4%) men and 119 (23.6%) women with a mean age of 45.5 ± 0.7 years. Nearly 99% (n = 500) of them were treatment-adherent. However, 45 (8.9%) mentioned the side effects as a reason for not following the treatment, revealing the non-adherence level of approximately 9%. About 93% of the patients were generally satisfied with the TB services, about 46% were satisfied with consultation and relational empathy and about 95% were satisfied with patient enablement. Being unsatisfied with TB services was associated with treatment non-adherence, inpatient treatment, drug-resistant TB, higher education, being unmarried, having a family income of below 50,000AMD (~120 USD) on average, being unsatisfied with consultation and empathy and place of residence. CONCLUSIONS: This study reports that TB patients are highly satisfied with TB care in Armenia. However, addressing specific characteristics associated with satisfaction may improve the TB program.

Medication noncompliance and patient satisfaction following percutaneous coronary intervention.

OBJECTIVES: This study evaluated the relationship between medication noncompliance and patient satisfaction in patients with drug-eluting stent revascularization in Armenia. BACKGROUND: Reasons for medication noncompliance are multifactorial--often related to health system, patient, condition, therapy, and socioeconomic factors. METHODS: The analytical cross-sectional survey used a simple random sample of patients aged 18 and over who had undergone percutaneous coronary artery intervention with drug-eluting stent from 2006 to 2008 (n = 271) at Nork Marash Medical Center, Yerevan, Armenia. Medication noncompliance was assessed using the Morisky Adherence Scale. Patient satisfaction items were selected from the Patient Satisfaction Questionnaire (PSQ-18). RESULTS: Respondents' mean age was 57.5 ± 9.8 years. Most (87.8%) were male. Nearly one-third of patients (31.0%) were noncompliant. Most reported good health (91.9%). Respondents most often cited out-of-pocket costs as a reason for noncompliance (19.2%). Age, gender, health status, smoking status, and cost were associated with medication noncompliance (P < 0.05). Noncompliance was not associated with elapsed time after the intervention or satisfaction (P > 0.05). Medication noncompliance was positively related to cost (odds ratio [OR]= 2.57, 95% CI = 1.33-4.97) and inversely related to health status (OR = 0.46, 95% CI = 0.25-0.85) and age (OR = 0.94, 95% CI = 0.91-0.97). CONCLUSION: Medication noncompliance is a multifactorial problem. Strategies reducing the economic burden on patients should improve compliance and, thus, treatment outcomes. These findings further efforts to benchmark performance in Armenia and other post-Soviet countries against western standards and experiences.