Patient and health-care provider experience of a person-centred, multidisciplinary, psychosocial support and harm reduction programme for patients with harmful use of alcohol and drug-resistant tuberculosis in Minsk, Belarus.

BACKGROUND: Tuberculosis (TB) often concentrates in groups of people with complex health and social issues, including alcohol use disorders (AUD). Risk of TB, and poor TB treatment outcomes, are substantially elevated in people who have AUD. Médecins sans Frontières and the Belarus Ministry of Health have worked to improve treatment adherence in patients with multi-drug or rifampicin resistant (MDR/RR)-TB and harmful use of alcohol. In 2016, a person-centred, multidisciplinary, psychosocial support and harm reduction programme delivered by TB doctors, counsellors, psychiatrists, health-educators, and social workers was initiated. In 2020, we described patient and provider experiences within the programme as part of a wider evaluation. METHODS: We recruited 12 patients and 20 health-care workers, using purposive sampling, for in-depth individual interviews and focus group discussions. We used a participant-led, flexible, exploratory approach, enabling participants and the interviewer to shape topics of conversation. Qualitative data were coded manually and analysed thematically. As part of the analysis process, identified themes were shared with health-care worker participants to enable their reflections to be incorporated into the findings. RESULTS: Key themes related to the patients' and practitioners experience of having and treating MDRTB with associated complex health and social issues were: fragility and despair and guidance, trust and health. Prejudice and marginalisation were global to both themes. Counsellors and other health workers built a trusting relationship with patients, enabling guidance through a multi-disciplinary approach, which supported patients to achieve their vision of health. This guidance was achieved by a team of social workers, counsellors, doctors and health-educators who provided professional and individualised help for patients' illnesses, personal or interpersonal problems, administrative tasks, and job searches. CONCLUSIONS: Patients with MDR/RR-TB and harmful use of alcohol faced complex issues during treatment. Our findings describe how person-centred, multi-disciplinary, psychosocial support helped patients in this setting to cope with these challenges and complete the treatment programme. We recommend that these findings are used to: i) inform programmatic changes to further boost the person-centred care nature of this program; and ii) advocate for this type of person-centred care approach to be rolled out across Belarus, and in contexts that face similar challenges.

A Médecins Sans Frontières Ethics Framework for Humanitarian Innovation.

Kiran Jobanputra and colleagues describe an ethics framework to support the ethics oversight of innovation projects in medical humanitarian contexts.

"I can also serve as an inspiration": a qualitative study of the TB&Me blogging experience and its role in MDR-TB treatment.

BACKGROUND: In 2011, Médecins Sans Frontières (MSF) established a blogging project, "TB&Me," to enable patients with multidrug-resistant tuberculosis (MDR-TB) to share their experiences. By September 2012, 13 MDR-TB patients had blogged, either directly or with assistance, from the UK, Australia, Philippines, Swaziland, Central African Republic, Uganda, South Africa, India, and Armenia. Due to the lack of research on the potential for social media to support MDR-TB treatment and the innovative nature of the blog, we decided to conduct a qualitative study to examine patient and staff experiences. Our aim was to identify potential risks and benefits associated with blogging to enable us to determine whether social media had a role to play in supporting patients with MDR-TB. METHODS AND FINDINGS: Participants were identified and selected purposively. TB&Me bloggers, project staff, MSF headquarters staff involved with TB and WHO European Region TB policy advisors were invited to participate in a semi-structured interview. Twenty interviews were conducted (five with bloggers). Data analysis drew upon principles of grounded theory, with constant comparison of data, cases and categories, and attention to deviant cases. We found that the TB&Me blog was associated with identified health benefits, with no reported instances of harm. There were three main findings: blogging was reported as useful for adherence to DR-TB treatment and supportive of the treatment-taking process by all bloggers and project staff; blogging provided support to patients (peer support, shared experience and reduction in isolation); and the blog was perceived as giving patients strength and voice. CONCLUSION: The TB&Me blog was seen to be associated with positive identified health and emotional benefits. Component 5 of the Stop TB Global Plan highlights the importance of empowering TB patients and communities. Blogging could be a useful tool to help achieve that ambition.

Should mortality data for the elderly be collected routinely in emergencies? The practical challenges of age-disaggregated surveillance systems.

Data on the elderly are rarely collected in humanitarian emergencies. During a refugee crisis in South Sudan, Médecins Sans Frontières developed a prospective mortality surveillance system collecting data for those aged ≥50 years and found that the elderly were dying at five times the rate of those aged 5-49 years. Practical and ethical issues arose. Were reported ages accurate? Since no baseline exists, what does the mortality rate mean? Should programmatic changes be made without evidence that these would reduce the elderly mortality rate? We outline issues to be addressed to enable informed decisions on response to elderly populations in emergency settings.

TB treatment in a chronic complex emergency: treatment outcomes and experiences in Somalia.

BACKGROUND: Médecins Sans Frontières (MSF) provides TB treatment in Galkayo and Marere in Somalia. MSF international supervisory staff withdrew in 2008 owing to insecurity but maintained daily communication with Somali staff. In this paper, we aimed to assess the feasibility of treating TB in a complex emergency setting and describe the programme adaptations implemented to facilitate acceptable treatment outcomes. METHODS: Routinely collected treatment data from 2005-2012 were retrospectively analysed. In multivariate analyses, factors associated with successful outcome (cure or completion versus failure, death and default) were assessed, including the presence of international supervisory staff. Informal interviews were conducted with Somali staff regarding programmatic factors affecting patient management and perceived reasons for default. RESULTS: In total, 6167 patients were admitted (34.8% female; median age 24.0 years [IQR 13.0-38.0 years]). Treatment success was 79% (programme range 69-87%). Presence of international staff did not improve outcomes (adjusted OR 0.85, 95% CI 0.66-1.09; p=0.27). Perceived reasons for default included being away from family, nomadic group, insecurity, travel cost, need to return to grazing land or feeling better. CONCLUSIONS: Despite the challenges, a high percentage of patients were successfully treated. Treatment outcomes were not adversely affected by withdrawal of international supervisory staff.

Counselling in humanitarian settings: a retrospective analysis of 18 individual-focused non-specialised counselling programmes.

BACKGROUND: Médecins Sans Frontières (MSF) provides individual counselling interventions in medical humanitarian programmes in contexts affected by conflict and violence. Although mental health and psychosocial interventions are a common part of the humanitarian response, little is known about how the profile and outcomes for individuals seeking care differs across contexts. We did a retrospective analysis of routine programme data to determine who accessed MSF counselling services and why, and the individual and programmatic risk factors for poor outcomes. METHODS: We analysed data from 18 mental health projects run by MSF in 2009 in eight countries. Outcome measures were client-rating scores (1-10 scale; 1 worst) for complaint severity and functioning and counsellor assessment. The effect of client and programme factors on outcomes was assessed by multiple regression analysis. Logistic regression was used to assess binary outcome variables. RESULTS: 48704 counselling sessions were held with 14963 individuals. Excluding women-focused projects, 66.8% of patients were women. Mean (SD) age was 33.3 (14.1) years. Anxiety-related complaints were the most common (35.0%), followed by family-related problems (15.7%), mood-related problems (14.1%) and physical complaints (13.7%). Only 2.0% presented with a serious mental health condition. 27.2% did not identify a traumatic precipitating event. 24.6% identified domestic discord or violence and 17.5% psychological violence as the precipitating event. 6244 (43.9%) had only one session. For 91% of 7837 who returned, the counsellor reported the problem had decreased or resolved. The mean (SD) complaint rating improved by 4.7 (2.4) points (p < 0.001) and by 4.2 (2.3, p < 0.001) for functional rating. Risk factors for poorer outcomes were few sessions, non-conflict setting (stable or societal violence settings), serious mental health condition, or attending a large, recently opened project. CONCLUSIONS: The majority of clients accessing counselling services present with anxiety related complaints. Attrition rates were high. Good outcomes were recorded among those who attended for more than one visit. Lessons learned included the importance of adaptation of approach in non-conflict contexts such as societal violence or post-conflict contexts. There is a need for further research to evaluate the intervention against a control group.

Provision of antiretroviral treatment in conflict settings: the experience of Médecins Sans Frontières.

INTRODUCTION: Many countries ravaged by conflict have substantial morbidity and mortality attributed to HIV/AIDS yet HIV treatment is uncommonly available. Universal access to HIV care cannot be achieved unless the needs of populations in conflict-affected areas are addressed. METHODS: From 2003 Médecins Sans Frontières introduced HIV care, including antiretroviral therapy, into 24 programmes in conflict or post-conflict settings, mainly in sub-Saharan Africa. HIV care and treatment activities were usually integrated within other medical activities. Project data collected in the Fuchia software system were analysed and outcomes compared with ART-LINC data. Programme reports and other relevant documents and interviews with local and headquarters staff were used to develop lessons learned. RESULTS: In the 22 programmes where ART was initiated, more than 10,500 people were diagnosed with HIV and received medical care, and 4555 commenced antiretroviral therapy, including 348 children. Complete data were available for adults in 20 programmes (n = 4145). At analysis, 2645 (64%) remained on ART, 422 (10%) had died, 466 (11%) lost to follow-up, 417 (10%) transferred to another programme, and 195 (5%) had an unclear outcome. Median 12-month mortality and loss to follow-up were 9% and 11% respectively, and median 6-month CD4 gain was 129 cells/mm 3.Patient outcomes on treatment were comparable to those in stable resource-limited settings, and individuals and communities obtained significant benefits from access to HIV treatment. Programme disruption through instability was uncommon with only one program experiencing interruption to services, and programs were adapted to allow for disruption and population movements. Integration of HIV activities strengthened other health activities contributing to health benefits for all victims of conflict and increasing the potential sustainability for implemented activities. CONCLUSIONS: With commitment, simplified treatment and monitoring, and adaptations for potential instability, HIV treatment can be feasibly and effectively provided in conflict or post-conflict settings.