Gender-related factors associated with delayed diagnosis of tuberculosis in Eastern Europe and Central Asia

Abstract Tuberculosis (TB), a preventable and treatable disease, yearly affects millions of people and takes more than a million lives. Recognizing the symptoms and obtaining the correct diagnosis are vital steps towards treatment and cure. How timely a person with TB gets diagnosed may be influenced by biological differences between the sexes, and factors that are linked to the person’s gender, in the context of the prevailing gender norms. According to our hypothesis, gender-related factors contribute to delays in the diagnosis of TB. We investigated four countries (Georgia, Kazakhstan, Republic of Moldova, and Tajikistan) of Eastern Europe and Central Asia (EECA) - a region with a high burden of drug-resistant TB, scarcity of gender-related TB information, and varying gender equality. Retrospective information was collected directly from the people with a history of TB - through in-depth interviews and focus group discussions. We did not find differences between genders in the way participants recognized TB symptoms. In three countries women de-prioritized seeking diagnosis because of their lack of access to finances, and household-related obligations. In all four countries, men, traditionally carrying the weight of economically supporting the family, tended to postpone TB diagnosis. In two countries women experienced stigma more often than men, and it was a deterrent factor to seeking healthcare. The role of gender in obtaining the correct diagnosis came forth only among the respondents from Georgia and to some extent from Kazakhstan. We conclude that there are barriers to health care seeking and TB diagnosis that affect differently women, men and gender-diverse persons in EECA Region

The use of digital technologies in adherence to anti-tuberculosis treatment.

Tuberculosis kills over 1.5 million people per year, particularly in low- and middle-income countries. Despite recent advances, regimens are at least several months in length, which can be problematic for persons with tuberculosis. In the last decade, digital adherence technologies (DATs) have been used both to monitor and promote dose-taking. As interventions, DATs can be reminders for dose-taking and generate digital dosing histories to help triage patients. The evidence for DATs improving treatment outcomes as a result of improving adherence is mixed. Emerging evidence suggests that persons with tuberculosis value DAT functions that foster a feeling of being ‘cared for’ by the health system. DATs should be embedded within, rather than used as the sole replacement for, comprehensive care packages. As monitors of dose-taking, DATs provide rich dose-by-dose datasets for use in research and allow for greater empowerment of persons with tuberculosis than the directly observed therapy (DOT) used previously. They may, however, not be a perfect proxy for 2 adherence

Costs of Digital Adherence Technologies for Tuberculosis Treatment Support, 2018–2021

Digital adherence technologies are increasingly used to support tuberculosis (TB) treatment adherence. Using microcosting, we estimated healthcare system costs (in 2022 US dollars) of 2 digital adherence technologies, 99DOTS medication sleeves and video-observed therapy (VOT), implemented in demonstration projects during 2018–2021. We also obtained cost estimates for standard directly observed therapy (DOT). Estimated per-person costs of 99DOTS for drug-sensitive TB were $98 in Bangladesh (n = 719),$119 in the Philippines (n = 396), and $174 in Tanzania (n = 976). Estimated per-person costs of VOT were$1, 154 in Haiti (87 drug-sensitive), $304 in Moldova (173 drug-sensitive),$452 in Moldova (135 drug-resistant), and $661 in the Philippines (110 drug-resistant). 99DOTS costs may be similar to or less expensive than standard DOT. VOT is more expensive, although in some settings, labor cost offsets or economies of scale may yield savings. 99DOTS and VOT may yield savings to local programs if donors cover infrastructure costs

Assessing tuberculosis control priorities in high-burden settings: a modelling approach

Summary: Background: In the context of WHO's End TB strategy, there is a need to focus future control efforts on those interventions and innovations that would be most effective in accelerating declines in tuberculosis burden. Using a modelling approach to link the tuberculosis care cascade to transmission, we aimed to identify which improvements in the cascade would yield the greatest effect on incidence and mortality. Methods: We engaged with national tuberculosis programmes in three country settings (India, Kenya, and Moldova) as illustrative examples of settings with a large private sector (India), a high HIV burden (Kenya), and a high burden of multidrug resistance (Moldova). We collated WHO country burden estimates, routine surveillance data, and tuberculosis prevalence surveys from 2011 (for India) and 2016 (for Kenya). Linking the tuberculosis care cascade to tuberculosis transmission using a mathematical model with Bayesian melding in each setting, we examined which cascade shortfalls would have the greatest effect on incidence and mortality, and how the cascade could be used to monitor future control efforts. Findings: Modelling suggests that combined measures to strengthen the care cascade could reduce cumulative tuberculosis incidence by 38% (95% Bayesian credible intervals 27–43) in India, 31% (25–41) in Kenya, and 27% (17–41) in Moldova between 2018 and 2035. For both incidence and mortality, modelling suggests that the most important cascade losses are the proportion of patients visiting the private health-care sector in India, missed diagnosis in health-care settings in Kenya, and drug sensitivity testing in Moldova. In all settings, the most influential delay is the interval before a patient's first presentation for care. In future interventions, the proportion of individuals with tuberculosis who are on high-quality treatment could offer a more robust monitoring tool than routine notifications of tuberculosis. Interpretation: Linked to transmission, the care cascade can be valuable, not only for improving patient outcomes but also in identifying and monitoring programmatic priorities to reduce tuberculosis incidence and mortality. Funding: US Agency for International Development, Stop TB Partnership, UK Medical Research Council, and Department for International Development