Strategies to reduce pre-treatment loss to follow-up and improve successful patient outcomes in a TB hotspot

The direct and indirect costs to individuals and households of accessing care are a critical barrier to TB treatment initiation and completion with poorer households incurring greater costs. While the associations between poverty and TB infection, TB disease and TB treatment outcomes are well documented there have been very few studies of economic interventions to improve TB outcomes. Other important barriers to successful TB treatment include health system weaknesses and unproductive patient-provider interactions resulting in limited patient motivation and understanding. In this study we will explore the effects of two interventions: 1) counselling patients before and after a TB test is performed and 2) giving patients limited financial support on the rates of TB treatment initiation and completion.

Up to 25% of people with TB in South Africa do not initiate treatment (pre-treatment loss to follow-up) and successful patient outcomes (SPO) are achieved in only 79% of those initiating TB treatment.[1] Pre-treatment loss to follow-up (PTLFU) of patients with microbiologically confirmed TB is a major obstacle to achieving population TB control since many of these individuals are highly infectious.[2] Reducing PTLFU by 50% (from 16% to 8%) could have a potent impact on decreasing TB incidence in South Africa.[1] Health system side factors contributing to PTLFU include slow sputum turn around times, long queues, and staff attitudes. While long sputum turnaround times have been associated with PTLFU, implementation of Xpert MTB/Rif has shown little or no benefit in reducing PTLFU.[3-5] Patient side factors that contribute to PTLFU include death, limited understanding of TB, and the direct and indirect costs of accessing care which are often catastrophic.[2, 6-8]

The direct and indirect costs to individuals and households of accessing care are a critical barrier to TB treatment initiation and completion with poorer households incurring greater costs.[6] While the associations between poverty and TB infection, TB disease and TB treatment outcomes are well documented there have been very few trials of economic interventions to improve TB outcomes with a recent Cochrane review identifying only 3 randomised studies. Achieving successful patient outcomes for TB also requires productive patient-provider interactions.[9]

We will conduct three studies to assess the effect and cost-effectiveness of a combination of patient supportive interventions, combined with a continuous quality improvement (CQI) approach to reduce PTLFU and improve SPOs within clinics within a TB hotspot. The patient supportive interventions include pre- and post-test counselling and conditional cash transfers to cover transport and other costs of accessing care. Study 1 will be a stepped-wedge study of pre- and post- TB test counselling together with a once off conditional cash transfer among adults (>18 years) undergoing investigation for pulmonary tuberculosis attending 12 health facilities implementing CQI programmes within the hotspot. Study 2 will be a randomised controlled trial of conditional cash transfers among 1200 adult participants with pulmonary TB commencing TB treatment. Cash transfers (~$10) will be provided at baseline, 2 weeks, and 1, 2, 5 and 6 months conditional on clinic attendance. Study 3 will be a health economics study using data from the first two studies to determine cost-effectiveness of the interventions.