Incomplete sputum smear microscopy monitoring among smear-positive tuberculosis patients in Uganda.

SETTING: All 11 tuberculosis (TB) diagnostic and treatment units in Kyankwanzi and Kiboga Districts in Uganda. OBJECTIVES: To determine the frequency of, factors associated with and barriers related to incomplete anti-tuberculosis treatment sputum monitoring. DESIGN: Data were abstracted from anti-tuberculosis treatment and laboratory registers of sputum smear-positive patients who started treatment between January 2009 and December 2011 in the study districts. Patients missing documentation for any smear results at 2 or 3, 5, and 6 or 8 months were classified as having incomplete monitoring. Health providers and patients were interviewed about barriers to sputum monitoring. RESULTS: Overall, 272 (55%) of 492 patients had incomplete monitoring: 16% (78/492) at 2 or 3 months, 39% (181/465) at 5 months and 28% (119/428) at 6 or 8 months of treatment. More sputum results were recorded in laboratory than in TB treatment registers. Incomplete monitoring was significantly associated with being male, living in Kyankwanzi District and not receiving directly observed treatment. Patients' inability to produce sputum, long laboratory waiting times, and insufficient patient and provider education were primary reasons for incomplete monitoring. CONCLUSION: Over half of patients missed at least one smear result during treatment, which has implications for treatment monitoring and treatment outcomes in Uganda.

Cost-utility of tuberculosis prevention among HIV-infected adults in Kampala, Uganda.

SETTING: Treatment of latent tuberculosis (TB) infection using isoniazid preventive therapy (IPT) in a human immunodeficiency virus (HIV) volunteer counseling and testing center in Kampala, Uganda. OBJECTIVE: To analyze the cost-utility of an IPT program for persons newly diagnosed with HIV. DESIGN: The cost-utility analysis of the IPT program was conducted using Markov cohort simulation methods. Newly diagnosed HIV-infected persons were evaluated using tuberculin skin test (TST); those with positive TST were offered IPT for 9 months (targeted testing strategy). An alternative strategy of offering IPT to all HIV-infected clients without TST screening was also evaluated (treat all strategy). The cost-utility of targeted testing was compared to the 'no program' and the 'treat all' strategies. RESULTS: The IPT program with the targeted testing strategy would produce 11 quality-adjusted life-years (QALYs) per 100 HIV-infected clients compared to no program. Offering IPT using the treat all strategy gained an additional 30 QALYs per 100 clients compared to targeted testing. Compared to no program, the incremental cost-utility of the targeted testing program was US$102/QALY gained. The cost-utility of the IPT program under the treat all strategy was US$106/QALY gained compared to the targeted testing strategy. CONCLUSIONS: The provision of IPT for HIV-infected persons was cost-effective. The use of TST screening prior to IPT reduced costs per QALY gained, but saved fewer overall QALYs.

Tuberculosis case finding and preventive therapy in an HIV voluntary counseling and testing center in Uganda.

SETTING: A large, urban human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) center in Kampala, Uganda. OBJECTIVE: Tuberculosis (TB) is a leading cause of morbidity and mortality in persons with HIV infection in sub-Saharan Africa. Intensified TB case finding and use of isoniazid preventive therapy (IPT) for latent infection reduces the burden of TB, but few programs have been implemented due to concerns about feasibility. DESIGN: Retrospective evaluation of a TB case finding and IPT program. RESULTS: Over a 25-month period, 6305 patients newly diagnosed with HIV infection underwent evaluation: 293 (5%) had TB disease; 1955 (37%) patients were not eligible for preventive therapy because they lived > 20 km away, had advanced HIV disease, or had previously had TB. Of 3366 who had a tuberculin skin test (TST) placed, 2548 (76%) had the TST read; 894 (35%) of these were positive. Of 506 persons who started treatment, 335 (66%) completed it. CONCLUSION: This unique program was feasible, detected a high proportion of undiagnosed TB, and successfully treated persons with latent infection. Expanding access to HIV VCT as well as collaboration between HIV/ AIDS and TB programs can increase the proportion of HIV-infected persons who can benefit from these programs.

Cost-effectiveness of including tuberculin skin testing in an IPT program for HIV-infected persons in Uganda.

SETTING: Tuberculosis (TB) is the most common opportunistic infection among persons with human immunodeficiency virus or the acquired immune-deficiency syndrome (HIV/AIDS). Isoniazid preventive therapy (IPT) effectively treats latent TB infection (LTBI) and prevents progression to active TB. OBJECTIVE: To analyse the costs and cost-effectiveness of tuberculin skin testing (TST) prior to offering IPT. DESIGN: We implemented a program for LTBI screening and IPT using TST for persons with HIV at a voluntary counseling and testing (VCT) center in Kampala, Uganda. Cost-effectiveness analyses using Markov methods were adopted to compare strategies of using and not using TST before offering IPT. RESULTS: The program enrolled 7073 persons with HIV. Based on the prevalence of LTBI in the population, 34/100 HIV-infected patients would benefit from IPT. The results showed that 28% of LTBI patients would be treated using the TST strategy, and 40% would be treated with a non-TST strategy. Compared to no intervention, the estimated incremental cost of identifying and providing IPT using TST was dollars 211 per patient; the incremental cost using a non-TST strategy was dollars 768 per patient. CONCLUSION: At a large VCT center in Uganda, the inclusion of TST to identify the HIV-infected persons who will most benefit from IPT is cost-effective.

Implementation of the DOTS strategy for tuberculosis control in rural Kiboga District, Uganda, offering patients the option of treatment supervision in the community, 1998-1999.

SETTING: Kiboga District, a rural district in central Uganda. OBJECTIVE: As part of routine tuberculosis control programme operations, to measure the effectiveness and acceptability of community-based tuberculosis (TB) care using the directly observed treatment, short-course (DOTS) strategy for TB control. The implementation of the DOTS strategy with active participation of local communities in providing the option of treatment supervision in the community is known in Uganda as community-based DOTS (CB-DOTS). DESIGN: Effectiveness was measured by comparing TB case-finding and treatment outcomes before and after the introduction of CB-DOTS in 1998. Acceptability was measured by administering a knowledge, attitudes and beliefs questionnaire to community members, health care workers and TB patients before and after the intervention. RESULTS: A total of 540 TB patients were registered in the control period (1995-1997) before the introduction of CB-DOTS, and 450 were registered in the intervention period (1998-1999) after the implementation of CB-DOTS. Following the implementation of CB-DOTS, treatment success among new smear-positive pulmonary TB cases increased from 56% to 74% (RR 1.3, 95%CI 1.2-1.5, P < 0.001) and treatment interruption decreased from 23% to 1% (RR 16.5, 95%CI 6.1-44.7, P < 0.001). There was no significant difference in the proportion of deaths before and after the implementation of CB-DOTS (15% vs. 14% for new smear-positive pulmonary, and 38% vs. 29% for new smear-negative and extra-pulmonary TB cases). The acceptability of CB-DOTS was very high among those interviewed, mainly because CB-DOTS improved access to TB care, decreased costs and enabled patients to stay with their families. CONCLUSIONS: In enabling patients to choose TB treatment supervision in the community, CB-DOTS provided a highly effective and acceptable additional option to conventional TB care. Efforts are underway to address the high case fatality rates in both study groups before and after the introduction of CB-DOTS. CB-DOTS is an example of shared responsibility between health services and communities in tackling a major public health priority.

Cost and cost-effectiveness of community-based care for tuberculosis patients in rural Uganda.

SETTING: Kiboga district, a rural area in Central Uganda. OBJECTIVE: To assess the cost and cost-effectiveness of community-based care for new smear-positive pulmonary tuberculosis patients compared with conventional hospital-based care. METHODS: Costs were analysed from the perspective of health services, patients, and community volunteers in 1998 US dollars, using standard methods. Cost-effectiveness was calculated as the cost per patient successfully treated. FINDINGS: The cost per patient treated for new smear-positive patients was dollars 510 with the conventional hospital-based approach to care (dollars 419 for the health system and dollars 91 for patients), and dollars 289 with community-based care (dollars 227 for health services, dollars 53 for patients and dollars 9 for volunteers). Important new costs associated with community-based care included programme supervision (dollars 18 and dollars 9 per patient at central and district levels, respectively) and training (dollars 18 per patient). The cost per patient successfully treated was dollars 911 with the hospital-based strategy and dollars 391 with community-based care, reflecting both lower costs and higher effectiveness (74% vs. 56% successful treatment rate) with community-based care. Length of hospital stay fell from an average of 60 to 19 days. CONCLUSION: There is a strong economic case for the implementation of community-based care in Uganda.