Introducing differentiated service delivery models for tuberculosis treatment: a pilot project to inform national policy in Uganda

IF 4.6 1区医学 Q2 IMMUNOLOGY

Journal of the International AIDS Society Pub Date : 2025-07-07 DOI:10.1002/jia2.26483

Odile Ferroussier-Davis, Deus Lukoye, Susan Alwedo, Mary N. Mudiope, Joanitah Nalunjogi, James Bruce Kirenga, Joseph N. Kabanda, Julius N. Kalamya, Benson Nasasira, Estella Birabwa, Seyoum Dejene, Miriam Murungi, Immaculate Ddumba, Brittany Moore, Aldomoro Burua, Henry Luzze, Ebony Quinto, Moorine Sekadde, Raymond Byaruhanga, Patrick Ajuna, Ivan Arinaitwe, Cordelia Katureebe, Proscovia Namuwenge, Michelle R. Adler, Stavia Turyahabwe

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引用次数: 0

Abstract

Introduction

Differentiated service delivery (DSD) models aim to tailor health services delivery to clients’ preferences and clinical characteristics while reducing the burden on health systems. In Uganda, DSD models developed for HIV care were adapted to the tuberculosis (TB) services context to mitigate disruptions from the COVID-19 pandemic and inform national efforts to improve TB care.

Methods

Beginning in April 2021, four facility-based and five community-based DSD models were implemented in 28 TB clinics in Kampala and Soroti Regions. All clients in the intensive (months 1–2) and continuation (months 3–6) phases of treatment were eligible. Client preference and clinician concurrence determined model choice. All models allowed TB medication dispensing intervals ranging from biweekly to multi-month dispensing (MMD; ≥ 2 months). Data abstracted in December 2022 from TB registers and DSD enrolment tracking tools at 21 of 28 implementing facilities were used to evaluate the intervention. The TB treatment success rate (i.e. proportion cured or who completed treatment, vs. those who died, failed, were lost-to-follow-up or had no recorded outcome) in the DSD cohort was compared to facilities’ 2018–2019 results using Fischer's exact test.

Results

Most facilities offered one (Kampala) or two (Soroti) facility-based models and one community-based model. Among 1864 TB clients enrolled between April 2021 and March 2022, 1822 (97.7%) used ≥ 1 DSD models; 210/1822 (11.5%) ever switched models. Overall, 70.5% (1284/1822) of clients enrolled in ≥ 1 facility-based model and 40.5% (737/1822) in ≥ 1 community-based model. The use of community-based models increased during the continuation phase. Facility-Based Individual Management and Home Delivery were the most-used models. In the intensive phase, the longest medication dispensation interval was biweekly for 50.0% of patients, monthly for 41.3% and MMD for 8.8%. During the continuation phase, the longest interval was biweekly for 0.6%, monthly for 71.7% and MMD for 27.6%. Overall, 1582/1864 (84.9%) clients were successfully treated, compared to 858/1177 (72.9%) in 2018–2019 (p < 0.001). Seven (0.4%) patients failed treatment, 32 (1.7%) were lost to follow-up, 101 (5.4%) died and 142 (7.6%) were not evaluated.

Conclusions

TB DSD models were successfully implemented. TB treatment outcomes under DSD compared favourably to historical outcomes. Investigating factors affecting MMD use and model choice could further inform programme design.

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为结核病治疗引入差异化服务提供模式：为乌干达国家政策提供信息的试点项目

差别化服务提供（DSD）模式旨在根据客户的偏好和临床特征定制卫生服务提供，同时减轻卫生系统的负担。在乌干达，为艾滋病毒护理开发的DSD模型已适应结核病服务环境，以减轻COVID-19大流行带来的干扰，并为改善结核病护理的国家努力提供信息。方法从2021年4月开始，在坎帕拉和索罗蒂地区的28家结核病诊所实施了4种基于设施的DSD模型和5种基于社区的DSD模型。所有接受强化治疗（1-2个月）和继续治疗（3-6个月）的患者均符合条件。病人的偏好和临床医生的同意决定了模型的选择。所有模型允许结核病药物分配间隔从两周到数月分配(MMD；≥2个月)。2022年12月从28个实施设施中的21个的结核病登记和DSD登记跟踪工具中提取的数据用于评估干预措施。使用Fischer的精确测试，将DSD队列中的结核病治疗成功率（即治愈或完成治疗的比例，与死亡、失败、失访或无记录结果的比例）与设施2018-2019年的结果进行比较。结果大多数医院提供一种（坎帕拉）或两种（索罗蒂）基于医院的模式和一种基于社区的模式。在2021年4月至2022年3月期间入组的1864名结核病患者中，1822名（97.7%）使用≥1个DSD模型；210/1822（11.5%）曾经切换过型号。总体而言，70.5%（1284/1822）的患者入组≥1个以设施为基础的模型，40.5%（737/1822）的患者入组≥1个以社区为基础的模型。在延续阶段，基于社区的模型的使用增加了。基于设施的个人管理和家庭交付是最常用的模式。在强化期，50.0%的患者用药间隔最长为两周，41.3%为每月，MMD为8.8%。在延续阶段，最长间隔为双周（0.6%），每月（71.7%）和MMD（27.6%）。总体而言，1582/1864例（84.9%）患者治疗成功，而2018-2019年为858/1177例（72.9%）。0.001)。治疗失败7例（0.4%），失访32例（1.7%），死亡101例（5.4%），未评价142例（7.6%）。结论TB DSD模型的建立是成功的。DSD下的结核病治疗结果优于历史结果。调查影响MMD使用和模型选择的因素可以进一步为方案设计提供信息。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Journal of the International AIDS Society IMMUNOLOGY-INFECTIOUS DISEASES

CiteScore

8.60

自引率

10.00%

发文量

186

审稿时长

>12 weeks

期刊介绍： The Journal of the International AIDS Society (JIAS) is a peer-reviewed and Open Access journal for the generation and dissemination of evidence from a wide range of disciplines: basic and biomedical sciences; behavioural sciences; epidemiology; clinical sciences; health economics and health policy; operations research and implementation sciences; and social sciences and humanities. Submission of HIV research carried out in low- and middle-income countries is strongly encouraged.