Decentralising drug-resistant TB treatment initiation services

Abstract

BACKGROUND: Drug-resistant TB (DR-TB) care coordination in Nigeria remains largely centralised, negatively impacting pre-treatment loss-to-follow-up (PTLTFU) and time-to-treatment initiation. We piloted a multi-faceted intervention and documented how the decentralisation of DR-TB services affected treatment enrolment and time-to-treatment initiation. METHODS: A quasi-experimental study was conducted in Southern Nigeria. Multi-level intervention consisting of eight components was implemented in the intervention states over a 15-month period. Data were collected using desk review proformas and analysed. RESULTS: At baseline, comparable proportions of people with DR-TB initiated treatment (x2 = 3.150, P = 0.076). Following decentralisation, a higher proportion (79.1%) of diagnosed persons with DR-TB in the intervention states were enrolled into treatment compared with the control states, 66.0% (x2 = 15.232, P, 0.001). There was a significant reduction in PTLTFU in the intervention states from 39.5% to 20.9% (P, 0.001) while PTLTFU increased from 31.9% to 34.0% (P = 0.689) in the control states. The median time-to-treatment initiation decreased from 17 days (interquartile range [IQR]: 10.0–32.0) at baseline to 14 days (IQR: 9.0–25.2) post-intervention. In the control states, median time-to-treatment initiation decreased from 21 days (IQR: 13.0– 35.3) at baseline to 15 days (8.0–36.0) post-intervention. CONCLUSION: Decentralising DR-TB services significantly reduced the diagnosis–enrolment gap and time-to-treatment initiation. Our findings provide contextual evidence for the expansion of decentralised services in Nigeria.