PREVALENCE AND FACTORS ASSOCIATED WITH TREATMENT INITIATION DELAYS AT MULTI DRUG RESISTANT TUBERCULOSIS TREATMENT CENTRES IN UGANDA

Abstract

Background: Multi Drug resistant tuberculosis (MDR-TB) is a major challenge to tuberculosis (TB) control. Globally, 3.9% of new and 21% of previously treated TB cases have MDR-TB. In Uganda, 1.4% of new and 12.1% of previously treated smear-positive patients have MDR-TB. Early detection of MDR-TB and prompt initiation on an effective treatment regimen are important factors in obtaining successful outcomes and preventing further spread of the disease. Despite efforts by Ministry of Health to improve treatment initiation among patients with MDR-TB, significant treatment initiation delay still exists. Objectives: This study aimed to determine the prevalence and assess factors associated with treatment initiation delay among patients diagnosed with MDR-TB at three tertiary referral hospitals in Uganda. Methods: A cross sectional study was done at Mulago, Hoima and Arua hospitals between December 2018 and February 2019. Both qualitative and quantitative data was collected. A total 203 patients and 15 healthcare workers were interviewed. Data was entered into Epi data, cleaned and exported into STATA for analysis. Qualitative data was analysed using QDA Miner Lite. Results: From the quantitative data, the overall prevalence of treatment initiation delay was 65.5%, (Mulago 73.6%, Hoima 53.9% and Arua 48.6%); median time to treatment initiation was 10 days (IQR 6 – 20). Delay was more common among HIV positive patients, female sex and age ≥ 35years at the diagnostic units and at the treatment centres, it was more pronounced at the national referral compared to regional referral hospitals. Awareness of MDR-TB was marginally protective against delay (adjusted RR 0.71, 95%CI 0.50 – 0.99 p = 0.05). Qualitative data interviews revealed that some of the factors associated with the delay included: delayed notification of Xpert® MTB/RIF results to patients, incomplete filling of laboratory Xpert® MTB/RIF request forms-making patient tracing impossible, lack of equipment and reagents to perform routine baseline/pre-treatment investigations, and lack of funds to transport patients to hospitals with MDR-TB treatment services. Conclusions: There is substantial delay in initiation of MDR-TB treatment after diagnosis by Xpert® MTB/RIF, more marked at the National Referral Hospital, HIV/MDR-TB co-infected patients, female patients and those ≥ 35 years. There is need for urgent interventions to reduce this delay to improve treatment outcome and decrease further disease transmission.