Do incentives improve tuberculosis treatment outcomes in the Republic of Moldova?

SETTING: Tuberculosis (TB) health facilities in the Republic of Moldova, where various incentives were provided to TB patients to improve treatment outcomes. OBJECTIVE: To compare treatment outcomes among new drug-susceptible TB patients registered for treatment before (2008) and after (2011) introduction of incentives. DESIGN: Retrospective cohort study using data from the national electronic patient database and incentive registers. RESULTS: Of 2378 patients registered in 2011, 1895 (80%) received incentives (cash, food vouchers, travel reimbursement). Compared to 2008 (no incentives, n = 2492), the patients registered with incentives in 2011 had higher treatment success (88% vs. 79%, P < 0.001) and lower proportions of unsuccessful outcomes: loss to follow-up (5% vs. 10%, P < 0.001), death (5% vs. 6%, P = 0.03) and failure (2% vs. 5%, P < 0.001). In multivariate analysis (log-binomial regression) using the intention-to-treat approach, provision of incentives was independently associated with an overall reduction in unsuccessful outcomes of 50% (RR 0.5, 95%CI 0.45-0.62, P < 0.001), after adjusting for other confounders such as sex, age, education, occupation, residence, homelessness, type of TB and human immunodeficiency virus status. CONCLUSION: Provision of incentives to TB patients significantly improved treatment success rates and needs to continue. Treatment retention increased, thus potentially preventing drug resistance, a serious problem in the Republic of Moldova.

Risk factors and timing of default from treatment for non-multidrug-resistant tuberculosis in Moldova.

SETTING: The Republic of Moldova, in Eastern Europe, has among the highest reported nationwide proportions of tuberculosis (TB) patients with multidrug-resistant tuberculosis (MDR-TB) worldwide. Default has been associated with increased mortality and amplification of drug resistance, and may contribute to the high MDR-TB rates in Moldova. OBJECTIVE: To assess risk factors and timing of default from treatment for non-MDR-TB from 2007 to 2010. DESIGN: A retrospective analysis of routine surveillance data on all non-MDR-TB patients reported. RESULTS: A total of 14.7% of non-MDR-TB patients defaulted from treatment during the study period. Independent risk factors for default included sociodemographic factors, such as homelessness, living alone, less formal education and spending substantial time outside Moldova in the year prior to diagnosis; and health-related factors such as human immunodeficiency virus co-infection, greater lung pathology and increasing TB drug resistance. Anti-tuberculosis treatment is usually initiated within an institutional setting in Moldova, and the default risk was highest in the month following the phase of hospitalized treatment (among civilians) and after leaving prison (among those diagnosed while incarcerated). CONCLUSIONS: Targeted interventions to increase treatment adherence for patients at highest risk of default, and improving the continuity of care for patients transitioning from institutional to community care may substantially reduce risk of default.