Delays in Tuberculosis Treatment smong people with pulmonary tuberculosis in East Africa: findings from a prospective cohort study

Abstract

Background. Although timely tuberculosis (TB) diagnosis and treatment are essential to TB elimination, care delays remain a challenge. Understanding factors associated with delayed TB diagnosis and treatment may inform interventions. Methods. The TB Sentinel Research Network of the International epidemiology Databases to Evaluate AIDS (IeDEA) is a prospective study of people aged ≥15 years with pulmonary TB. At sites in Eldoret, Kenya, and Mbarara, Uganda, questionnaires ascertained timing of recalled TB symptom onset, number/setting of healthcare visits prior to TB diagnosis, symptoms, demographics, food insecurity, and TB- and HIV-related stigma. Robust negative binomial regression was used to examine factors associated with longer overall duration from TB symptom onset to documented treatment initiation. Results. Among 264 participants—median age 33 years (IQR, 25–43 years), 67% male, 31% people with HIV, 51% urban residents—median duration from TB symptom onset to treatment initiation was 65.5 days (IQR, 33–131 days). Longer time to TB treatment was associated with female sex (adjusted incidence rate ratio [aIRR], 1.27 [95% CI, 1.00–1.61]); previous careseeking at a pharmacy (aIRR, 1.53 [95% CI, 1.22–1.92]), and presence of dyspnea (aIRR, 1.43 [95% CI, 1.09–1.86]) or fatigue (aIRR, 1.63 [95% CI, 1.11–2.37]) at initiation. Shorter duration to TB treatment was associated with HIV-positive status (aIRR, 0.50 [95% CI, .39–.64]). Among people with HIV, shorter duration to TB treatment was associated with CD4 count <200 cells/μL (aIRR, 0.63 [95% CI, .43–.93]). Conclusions. Interventions are needed to increase community-level TB diagnostic access, including at pharmacies and lower levels of care. Decentralized TB testing strategies and tailored interventions for groups with lower care access should be pursued.