A feasibility study using time-driven activity-based costing as a management tool for provider cost estimation: lessons from the national TB control program in Zimbabwe in 2018.

BACKGROUND: Insufficient cost data and limited capacity constrains the understanding of the actual resources required for effective TB control. This study used process maps and time-driven activity-based costing to document TB service delivery processes. The analysis identified the resources required to sustain TB services in Zimbabwe, as well as several opportunities for more effective and efficient use of available resources. METHODS: A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel's practical capacity and capacity cost rates were calculated on five cost domains. An MS Excel model calculated diagnostic and treatment costs. FINDINGS: Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Considerable variations were observed among the facilities in how health care professionals performed client registration, taking of vital signs, treatment follow-up, dispensing medicines and processing samples. The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost components were personnel (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3). CONCLUSION: TDABC is a feasible and effective costing and management tool in low-resource settings. The TDABC process maps and treatment costs revealed several opportunities for innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could produce better and more uniform TB treatments at significantly lower cost in Zimbabwe.

Disability, comorbidities and risk determinants at end of TB treatment in Kenya, Uganda, Zambia and Zimbabwe.

BACKGROUND: We examined the feasibility of assessing and referring adults successfully completing TB treatment for comorbidities, risk determinants and disability in health facilities in Kenya, Uganda, Zambia and Zimbabwe. METHODS: This was a cross-sectional study within national TB programmes. RESULTS: Health workers assessed 1,063 patients (78% of eligible) in a median of 22 min [IQR 16-35] and found it useful and feasible to accomplish in addition to other responsibilities. For comorbidities, 476 (44%) had HIV co-infection, 172 (16%) had high blood pressure (newly detected in 124), 43 (4%) had mental health disorders (newly detected in 33) and 36 (3%) had diabetes mellitus. The most common risk determinants were 'probable alcohol dependence' (15%) and malnutrition (14%). Disability, defined as walking <400 m in 6 min, was found in 151/882 (17%). Overall, 763 (72%) patients had at least one comorbidity, risk determinant and/or disability. At least two-thirds of eligible patients were referred for care, although 80% of those with disability needed referral outside their original health facility. CONCLUSIONS: Seven in 10 patients completing TB treatment had at least one comorbidity, risk determinant and/or disability. This emphasises the need for offering early patient-centred care, including pulmonary rehabilitation, to improve quality of life, reduce TB recurrence and increase long-term survival.

CONTEXTE: Nous avons examiné la faisabilité d'évaluer et de référer les adultes ayant terminé avec succès le traitement de la TB pour les comorbidités, les déterminants de risque et l'invalidité dans les établissements de santé au Kenya, en Ouganda, en Zambie et au Zimbabwe. MÉTHODES: Il s'agissait d'une étude transversale menée dans le cadre des programmes nationaux de lutte contre la TB. RÉSULTATS: Les agents de santé ont évalué 1 063 patients (78% des personnes éligibles) en médiane de 22 min (IQR 16­35) et ont jugé utile et réalisable d'accomplir cette tâche en plus de leurs autres responsabilités. Pour les comorbidités, 476 (44%) étaient co-infectés par le VIH, 172 (16%) souffraient d'hypertension artérielle (dont 124 nouvellement diagnostiqués), 43 (4%) présentaient des troubles de santé mentale (dont 33 nouvellement diagnostiqués) et 36 (3%) étaient diabétiques. Les déterminants de risque les plus courants étaient une « dépendance probable à l'alcool ¼ (15%) et la malnutrition (14%). L'invalidité, définie comme une marche <400 m en 6 min, a été observée chez 151/882 (17%) des patients. Dans l'ensemble, 763 (72%) des patients présentaient au moins une comorbidité, un déterminant de risque et/ou une invalidité. Au moins deux tiers des patients éligibles ont été référés pour des soins, bien que 80% de ceux souffrant d'invalidité aient besoin d'être référés en dehors de leur établissement de santé d'origine. CONCLUSIONS: Sept patients sur 10 ayant terminé le traitement de la TB présentaient au moins une comorbidité, un déterminant de risque et/ou une invalidité. Cela souligne la nécessité d'offrir des soins précoces centrés sur le patient, y compris une réadaptation pulmonaire, pour améliorer la qualité de vie, réduire la récurrence de la TB et augmenter la survie à long terme.

Case identification, retention and blood pressure control in Kenya.

BACKGROUND: Prevalence of hypertension in Africa is rising but it remains underdiagnosed and poorly controlled. In Kenya, only 22% of individuals known to have hypertension were on treatment, and only 51.7% were controlled. This study will assess screening outcomes, retention and blood pressure (BP) control of a hypertension programme in Kenya. DESIGN: This was a retrospective cohort study using data routinely collected between 2015 and 2018. All patients aged >18 years screened and treated in the programme were included. RESULTS: Of 663,028 screening encounters, 70.4% were female; the median age was 34 years. Overall, 19% of the study population, mainly males and older persons, had high BP higher rates. Of 66,981 patients started on treatment, the majority were females (71.2%); the median age was 55 years. Only 12% of patients were reported as having been retained after 12 months, and 48.6% of patients on treatment 10.5-13.5 months after enrolment had controlled BP. Older age and treatment at primary care level were associated with better retention and females had better BP control. CONCLUSIONS: The programme screened primarily females and younger individuals at lower risk. Retention was poor and close to half of patients retained had controlled BP. Hypertension programmes should target high-risk individuals, decentralise treatment, incorporate retention strategies and improve longitudinal data management.

CONTEXTE: La prévalence de l'hypertension en Afrique est en hausse, mais elle reste sous-diagnostiquée et mal contrôlée. Au Kenya, seulement 22% des individus avec diagnostic d'hypertension sont sous traitement et uniquement 51,7% d'entre eux ont une hypertension contrôlée. Nous avons étudié les résultats du dépistage, le maintien des patients sous traitement et le contrôle de la tension artérielle (BP) dans le cadre d'un programme de prise en charge de l'hypertension au Kenya. MÉTHODE: Nous avons réalisé une étude de cohorte rétrospective en utilisant des données de routine recueillies entre 2015 et 2018. Tous les patients âgés >18 ans dépistés et traités dans le cadre du programme ont été inclus. RÉSULTATS: Sur les 663 028 personnes dépistées, 70,4% étaient des femmes et l'âge médian était de 34 ans. Dans l'ensemble, 19% des personnes, en particulier les hommes et les personnes âgées, avaient une BP élevée. Sur 66 981 patients placés sous traitement, la majorité était des femmes (71,2%) et l'âge médian était de 55 ans. Seuls 12% des patients étaient toujours sous traitement après 12 mois, et 48,6% des patients qui étaient sous traitement 10,5­13,5 mois après l'inclusion avaient une BP contrôlée. Un âge avancé et un traitement reçu en centres de soins primaires étaient associés à un meilleur maintien sous traitement, et les femmes avaient une BP mieux contrôlée. CONCLUSIONS: Le programme a principalement dépisté des femmes et de jeunes adultes à faible risque. Le taux de maintien sous traitement était faible et près de la moitié des patients toujours sous traitement avaient une BP contrôlée. Les programmes de prise en charge de l'hypertension devraient cibler les personnes à haut risque, décentraliser le traitement, incorporer des stratégies de maintien sous traitement et améliorer la gestion des données longitudinales.

TB prevalence in Zimbabwe: a national cross-sectional survey, 2014.

BACKGROUND: We conducted the first national TB prevalence survey to provide accurate estimates of bacteriologically confirmed pulmonary TB disease among adults aged ≥15 years in 2014.METHODS: A TB symptoms screen and chest X-ray (CXR) were used to identify presumptive TB cases who submitted two sputum samples for smear microscopy, liquid and solid culture. Bacteriological confirmation included acid-fast bacilli smear positivity confirmed using Xpert® MTB/RIF and/or culture. Prevalence estimates were calculated using random effects logistic regression with multiple imputations and inverse probability weighting.RESULTS: Of 43,478 eligible participants, 33,736 (78%) were screened; of these 5,820 (17%) presumptive cases were identified. There were 107 (1.9%) bacteriologically confirmed TB cases, of which 23 (21%) were smear-positive. The adjusted prevalences of smear-positive and bacteriologically confirmed TB disease were respectively 82/100,000 population (95% CI 47-118/100,000) and 344/100,000 (95% CI 268-420/100,000), with an overall all-ages, all-forms TB prevalence of 275/100,000 population (95% CI 217-334/100,000). TB prevalence was higher in males, and age groups 35-44 and ≥65 years. CXR identified 93/107 (87%) cases vs. 39/107 (36%) using the symptom screen.CONCLUSION: Zimbabwe TB disease prevalence has decreased relative to prior estimates, possibly due to increased antiretroviral therapy coverage and successful national TB control strategies. Continued investments in TB diagnostics for improved case detection are required.

Hepatitis B infection in people living with HIV who initiate antiretroviral therapy in Zimbabwe.

SETTING: There is little information about the diagnosis and treatment of hepatitis B virus (HBV) infection in people living with HIV (PLHIV) in Zimbabwe despite recommendations that tenofovir (TDF) + lamivudine (3TC) is the most effective nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) backbone of antiretroviral therapy (ART) in those with dual infection. OBJECTIVE: To determine 1) numbers screened for hepatitis B surface antigen (HBsAg); 2) numbers diagnosed HBsAg-positive along with baseline characteristics; and 3) NRTI backbones used among PLHIV initiating first-line ART at Mpilo Opportunistic Infections Clinic, Bulawayo, Zimbabwe, between October 2017 and April 2019. DESIGN: This was a cross-sectional study using routinely collected data. RESULTS: Of the 422 PLHIV initiating first-line ART (median age 34 years, IQR 25-43), 361 (85%) were screened for HBV, with 10% being HBsAg-positive. HBsAg positivity was significantly associated with anaemia (adjusted prevalence ratio [aPR] 2.3, 95%CI 1.1-4.7) and elevated ala-nine transaminase levels (aPR 2.9, 95%CI 1.5-5.8). Of 38 PLHIV who were diagnosed HBsAg-positive, 30 (79%) were started on ART based on tenofovir (TDF) and lamivudine (3TC), seven were given abacavir (ABC) + 3TC-based ART and one was given zido vudine (ZDV) + 3TC-based ART. CONCLUSION: In PLHIV, HBV screening worked well, the prevalence of HIV-HBV co-infection was high and most patients received appropriate treatment for both conditions. Recommendations to improve screening, diagnosis and treatment of HIV-HBV co-infection are discussed.

Targeted active screening for tuberculosis in Zimbabwe: are field digital chest X-ray ratings reliable?

SETTING: Fifteen purposively selected districts in Zimbabwe in which targeted active screening for tuberculosis (Tas4TB) was conducted among TB high-risk groups (HRGs). There were 230 patients started on TB treatment on the basis of chest X-ray (CXR) results without corresponding bacteriological confirmation. OBJECTIVES: To determine 1) the percentage of agreements in digital CXR ratings by medical officers against final ratings by radiologist(s), 2) inter-rater agreement in CXR ratings between medical officers and radiologists, and 3) number (and proportion) of patients belonging to HRGs who were over-treated during Tas4TB. DESIGN: This was a cross-sectional study using programme data. RESULTS: A total of 168 patients had their CXRs rated by two independent radiologists. Discordances among the radiologists were resolved by a third index radiologist, who provided the final rating. κ scores were 0.01 (field ratings vs. Radiologist A); 0.02 (field ratings vs. Radiologist B); 0.74 (Radiologists A vs. B). The percentage agreement for field and final radiologist rating was 70% (95%CI 64-78). Around 29% (95%CI 23-36) of the patients were potentially over-treated during Tas4TB. CONCLUSION: Over a quarter of patients with presumptive TB are potentially over-treated during Tas4TB. Over-treatment is highest among those with previous contact with TB patients. Trainings of radiographers and medical officers may improve CXR ratings.

A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe.

SETTING: Ten districts and three cities in Zimbabwe. OBJECTIVE: To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone. DESIGN: Cross-sectional study using data from the ZimACF project. RESULTS: A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm. CONCLUSION: The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.

Feasibility and yield of screening for diabetes mellitus among tuberculosis patients in Harare, Zimbabwe.

SETTING: A resource-limited urban setting in Zimbabwe with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV). OBJECTIVES: To determine the feasibility and yield of diabetes mellitus (DM) screening among TB patients in primary health care facilities. DESIGN: A descriptive study. RESULTS: Of the 1617 TB patients registered at 10 pilot facilities, close to two thirds (60%) were male and 798 (49%) were bacteriologically confirmed. The median age was 37 years; two thirds (67%) were co-infected with HIV. A total of 1305 (89%) were screened for DM, and 111 (8.5%, 95% CI 7.0-10.2) were newly diagnosed with DM. Low TB notifying sites were more likely than high TB notifying sites to screen patients using random blood glucose (RBG) (83% vs. 79%; P < 0.04). Screening increased gradually per quarter over the study period. There were, however, notable losses along the screening cascade, the reasons for which will need to be explored in future studies. CONCLUSION: The study findings indicate the feasibility of DM screening among TB patients, with considerable yield of persons newly diagnosed with DM. Scaling up of this intervention will need to address the observed losses along the screening cascade.

Mobile targeted screening for tuberculosis in Zimbabwe: diagnosis, linkage to care and treatment outcomes.

SETTING: Targeted active screening for tuberculosis (Tas4TB) using mobile trucks in the community was implemented in 15 high TB burden districts in Zimbabwe. At-risk populations were screened for TB based on symptoms and chest radiography (CXR) results. Those with any positive symptom and/or an abnormal CXR had sputum collected for investigation and diagnosis and were linked to care and treatment if found to have TB. OBJECTIVE: To determine 1) the proportion and characteristics of those screened and diagnosed with TB; 2) the relationship between TB symptoms, CXR and diagnostic yields; and 3) the relationship between initiation of anti-TB treatment and treatment outcomes. DESIGN: Cohort study using routinely collected data. RESULTS: A total of 39 065 persons were screened, of whom 663 (1.7%) were diagnosed with TB; 126/663 (19.0%) were bacteriologically confirmed. The highest TB diagnostic yields were in symptomatic persons with CXRs suggestive of TB (19.4%), asymptomatic persons with CXRs suggestive of TB (8.4%) and persons at high-risk of TB (3.2%). For all diagnosed TB patients, pre-treatment loss to follow-up was 18.9% and treatment success was 59.9%. CONCLUSION: Tas4TB resulted in high diagnostic yields; however, linkage of diagnosis to care was poor. Reasons for loss to follow-up need to be better understood and rectified.

Has TB CARE I sputum transport improved access to culture services for retreatment tuberculosis patients in Zimbabwe?

Setting: Retreatment tuberculosis (TB) patients in Zimbabwe are investigated using microscopy, Xpert® MTB/RIF and culture + drug susceptibility testing (CDST). TB CARE I, a sputum transport service using motorcycles, was introduced to transport specimens between peripheral health facilities and laboratories, including National Reference Laboratories (NRLs). Objectives: To compare access to CDST and treatment outcomes among retreatment TB patients in facilities with and those without TB CARE I support. Design: This was a retrospective cohort study. Results: There were 187 patients from TB CARE I-supported facilities and 116 from non-TB CARE I facilities, with no difference in demographic characteristics. Altogether, specimens from 22 (12%) retreatment TB patients had successful CDST from TB CARE I facilities, which was not statistically significantly different from non-supported facilities (n = 14, 12%; P = 0.94). The median number of days from sputum collection to receipt at the NRL was lower in TB CARE I facilities than in non-supported facilities (median 6, interquartile range [IQR] 4-8 vs. median 8, IQR 6-13.5; P = 0.000). Favourable treatment outcomes were documented in 65% of patients under TB CARE I, significantly more than among patients in non-supported facilities (47%, P < 0.01). Conclusion: The process of sputum specimen collection for CDST was not different between TB CARE I and non-TB CARE I-supported health facilities, apart from a slightly shorter time. Ways to improve the current system are discussed.

Contexte : Les patients tuberculeux en retraitement au Zimbabwe bénéficient d'un bilan par microscopie, Xpert® MTB/RIF et culture + test de pharmacosensibilité (CDST). TB CARE I, un service de transport des crachats recourant à des motos, a été introduit afin de transporter les échantillons entre les structures de santé périphériques et les laboratoires, notamment les Laboratoires Nationaux de Référence (NRL).Objectif : Comparer les structures avec et sans soutien de TB CARE I, l'accès au CDST et les résultats du traitement parmi les patients en retraitement.Schéma : Etude rétrospective de cohorteRésultats : Il y a eu 187 patients de structures soutenues par TB CARE I et 116 patients de structures non soutenues par TB CARE I, sans différence en termes de caractéristiques démographiques. Au total, les échantillons de 22 patients (12%) TB en retraitement ont eu un CDST réussi dans les structures TB CARE I, ce qui n'a pas été très différent des patients des structures non soutenues (n = 14, 12% ; P = 0,94). Le nombre médian de jours depuis le recueil de crachats jusqu'à la réception au NRL a été plus faible dans les structures TB CARE I que dans les structures non soutenues (médiane = 6, intervalle interquartile [IQR] 4­8 contre médiane = 8, IQR 6­13,5 ; P = 0,0001). Des résultats favorables du traitement ont été documentés chez 65% des patients sous TB CARE I, ce qui a été significativement plus élevé que chez les patients dans les structures non soutenues (47% ; P < 0,01).Conclusion : Le processus de recueil d'échantillons de crachats pour le CDST n'a pas mis en évidence de différence entre les structures de santé soutenues I et non soutenues par TB CARE I, en dehors d'un délai légèrement plus court. On discute des manières d'améliorer le système actuel.

Marco de referencia: La investigación de los pacientes en retratamiento por tuberculosis (TB) en Zimbabwe comporta el examen microscópico, la prueba Xpert® MTB/RIF y el cultivo con pruebas de sensibilidad a los medicamentos (CDST). Se introdujo el servicio TB CARE I, que consiste en la utilización de motocicletas para el transporte de las muestras de esputo de los establecimientos periféricos de salud a los laboratorios, incluidos los Laboratorios Nacionales de Referencia.Objetivos: Comparar el acceso al CDST y el desenlace terapéutico de los pacientes en retratamiento atendidos en los establecimientos que cuentan con el servicio TB CARE I y los centros sin este apoyo.Método: Fue este un estudio de cohortes retrospectivo.Resultados: Participaron en el estudio 187 pacientes de centros que contaban con el servicio TB CARE I y 116 pacientes de centros sin este apoyo, cuyas características demográficas eran equivalentes. En conjunto, las muestras de 22 pacientes en retratamiento (12%) de establecimientos con respaldo del servicio TB CARE I obtuvieron resultados adecuados del CDST a los medicamentos; esta proporción fue equivalente a la de muestras de los centros sin el servicio de transporte (n = 14, 12%; P = 0,94). La mediana del número de días entre la recogida del esputo y la recepción en el Laboratorio Nacional de Referencia fue inferior en los establecimientos con el servicio TB CARE I que en los centros desprovistos del mismo (mediana 6 días, amplitud intercuartílica [IQR] 4­8 contra 8 días, IQR 6­13,5; P = 0,0001). Se documentaron desenlaces terapéuticos favorables en el 65% de los pacientes cubiertos por el servicio TB CARE I; esta proporción es significativamente más alta que en los pacientes de los establecimientos que no contaban con este apoyo (47%; P < 0,01).Conclusión: No se observaron diferencias en el proceso de recogida de muestras de esputo para CDST los medicamentos en los establecimientos que contaban o no con el respaldo del programa TB CARE I, con la excepción de un lapso de transporte un poco más corto en los primeros. En el artículo se discuten diversas formas de mejorar el sistema vigente.

Scaling up isoniazid preventive therapy in Zimbabwe: has operational research influenced policy and practice?

Setting: Following the operational research study conducted during the isoniazid preventive therapy (IPT) pilot phase in Zimbabwe, recommendations for improvement were adopted by the national antiretroviral therapy (ART) programme. Objectives: To compare before (January 2013-June 2014) and after the recommendations (July 2014-December 2015), the extent of IPT scale-up and IPT completion rates, and after the recommendations the risk factors for IPT non-completion, in 530 ART clinics. Design: Retrospective cohort study. Results: People living with the human immunodeficiency virus newly initiating IPT increased every quarter (Q), from 585 in Q 1, 2013 to 4246 in Q 4, 2015, with 5648 new IPT initiations in the 18 months before the recommendations compared to 20 513 in the 18 months after the recommendations were made. The number of ART clinics initiating IPT increased from 10 (2%) in Q 1, 2013 to 198 (37%) in Q 4, 2015. Overall IPT completion rates were 89% in the post-recommendation period compared with 81% in the pilot phase (P < 0.001). After adjusting for confounders, being lost to follow-up from clinic review visits 1 year prior to IPT initiation was associated with a higher risk of not completing IPT, while having synchronised IPT and ART resupplies was associated with a lower risk. Conclusions: Implementation of recommendations from the initial operational research study have improved IPT scale-up in Zimbabwe.

Contexte : A la suite d'une recherche opérationnelle réalisée pendant la phase pilote du traitement préventif par isoniazide (TPI) au Zimbabwe, des recommandations visant à une expansion ont été adoptées par le programme national de traitement antirétroviral (TAR).Objectifs : Dans 530 centres de TAR, comparer avant (janvier 2013 à juin 2014) et après les recommandations (juillet 2014 à décembre 2015), le degré d'expansion du TPI et ses taux d'achèvement, et après les recommandations, examiner les facteurs de risque de non achèvement.Schéma : Cohorte rétrospective.Résultats : Le nombre des personnes vivant avec le virus de l'immunodéficience humaine démarrant le TPI ont augmenté chaque trimestre de 585 pendant le premier trimestre de 2013 à 4246 pendant le quatrième trimestre de 2015, avec 5648 nouvelles mises en route du TPI dans les 18 mois avant les recommandations et 20 513 dans la période de 18 mois après les recommandations. Le nombre de centres de TAR mettant en route le TPI a augmenté de 10 (2%) au premier trimestre 2013 à 198 (37%) au quatrième trimestre 2015. Les taux d'ensemble d'achèvement du TPI ont été de 89% dans la période suivant les recommandations comparés à 81% pendant la phase pilote (P < 0,001). Après ajustement sur les facteurs de confusion, le fait d'être perdus de vue des consultations de suivi au centre 1 an avant la mise en route du TPI a été associé à un risque plus élevé de non achèvement du TPI, tandis que la synchronisation du renouvellement des fournitures du TPI et du TAR a été associée à un risque plus faible.Conclusions: Les recommandations émanant de la recherche opérationnelle initiale ont amélioré l'expansion du TPI au Zimbabwe.

Marco de referencia: El programa nacional de tratamiento antirretrovírico (TAR), tras una investigación operativa realizada durante la fase preliminar de aplicación del tratamiento preventivo con isoniazida (TPI) en Zimbabwe, adoptó las medidas de mejoramiento que se recomendaban.Objetivos: Comparar en 530 consultorios de suministro del TAR la magnitud de la ampliación de escala del TPI y las tasas de compleción del mismo, antes (de enero del 2013 a junio del 2014) y después (de julio del 2014 a diciembre del 2015) de la puesta en práctica de las recomendaciones, y después de su adopción, examinar los factores de riesgo de no completar el TPI.Método: Fue este un estudio de cohortes retrospectivo.Resultados: El número de personas infectadas por el virus de la inmunodeficiencia humana que iniciaban el TPI aumentó en cada trimestre, de 585 en el primer trimestre del 2013 a 4246 en el cuarto trimestre del 2015; se contabilizaron 5648 nuevos inicios del TPI en los 18 meses que precedieron la aplicación de las recomendaciones y 20 513 casos en los 18 meses que siguieron a la puesta en práctica de las mismas. El número de consultorios de TAR que iniciaban el TPI aumentó de 10 (2%) en el primer trimestre del 2013 a 198 (37%) en el cuarto trimestre del 2015. La tasa de compleción global del TPI fue 89% en el período posterior a las recomendaciones, comparada con 81% en la fase preliminar (P < 0,001). Tras corregir con respecto a las variables de confusión, la pérdida durante el seguimiento en las citas de control en el consultorio durante el año anterior a la iniciación del TPI se asoció con un mayor riesgo de no completar el TPI; al contrario, la sincronización del suministro del TPI y el TAR se asoció con una disminución del riesgo.Conclusión: La aplicación de las medidas recomendadas durante la investigación operativa inicial ha mejorado la ampliación de escala del suministro del TPI en Zimbabwe.

Implementation of the 'Test and Treat' policy for newly diagnosed people living with HIV in Zimbabwe in 2017.

Setting: Sixteen mission hospitals in Zimbabwe that are implementing the 'Test and Treat' programme for people living with the human immunodeficiency virus (HIV). Objectives: To assess linkages of HIV diagnosis to care and treatment, time taken from being diagnosed with HIV infection to initiation of antiretroviral therapy (ART) and 3-month programmatic outcomes for those starting ART. Design: Cross-sectional study using secondary data. Results: Among 972 people newly diagnosed with HIV, 915 (94%) enrolled for HIV care and 771 (79%) were initiated on ART. Enrolment in care and initiation on ART on the same day as testing occurred in respectively 864 (89%) and 628 (65%) newly diagnosed patients. Over 80% of those who underwent HIV testing in maternal and child health departments initiated ART on the same day. Of the 144 (16%) people in care who were not initiated on ART, the principal reason in 102 (71%) was being transferred out. Most patients (90%) on ART were retained in care at 3 months, with transfer out accounting for most of the remainder. Conclusion: The 'Test and Treat' approach was feasible and successful in getting newly HIV-infected people initiated early on ART. More research is needed to better understand the processes, benefits and potential risks.

Contexte : Seize hôpitaux de mission au Zimbabwe qui mettent en œuvre l'approche « Tester et Traiter ¼ pour les personnes vivant avec le virus de l'immunodéficience humaine (VIH).Objectif : Evaluer les liens entre le diagnostic du VIH et la prise en charge et le traitement, le délai entre le diagnostic d'infection à VIH et la mise en route du traitement antirétroviral (TAR) et les résultats à 3 mois des patients ayant mis en route le TAR.Schéma : Etude transversale recourant à des données secondaires.Résultats : Parmi 972 personnes ayant eu un diagnostic récent de VIH, 915 (94%) patients étaient enrôlés dans la prise en charge du VIH et 771 (79%) ont mis en route le TAR. L'enrôlement dans la prise en charge et la mise en route du TAR le même jour que le test a concerné respectivement 864 (89%) et 628 (65%) patients récemment diagnostiqués. Plus de 80% des patients testés pour le VIH dans des services de santé maternelle et infantile ont mis en route le TAR le même jour. Sur les 144 (16%) patients pris en charge qui n'ont pas été mis sous TAR, la raison principale chez 102 (71%) a été un transfert. La majorité des patients (90%) sous TAR ont été retenus en traitement à 3 mois, la plupart des autres ayant été transférés.Conclusion : L'approche « Tester et Traiter ¼ a été faisable et a réussi à ce que les patients récemment infectés par le VIH soient précocement mis sous TAR. Davantage de recherche est nécessaire afin de mieux comprendre les processus, les bénéfices et les risques potentiels.

Marco de Referencia: Diez y seis hospitales de misión en Zimbabwe que introducen la estrategia 'Análisis y Tratamiento' para todas las personas con infección por el virus de la inmunodeficiencia humana (VIH).Objetivos: Evaluar el vínculo entre los servicios de diagnóstico, atención y tratamiento de la infección por el VIH, el tiempo que transcurre entre el diagnóstico de la infección y el inicio del tratamiento antirretrovírico (TAR) y los resultados programáticos a 3 meses, en las personas que inician el TAR.Método: Fue este un estudio transversal realizado a partir de datos secundarios.Resultados: De las 972 personas con diagnóstico reciente de infección por el VIH, 915 se inscribieron en los servicios de atención (94%) y 771 iniciaron TAR (79%). La inscripción a los servicios del VIH y el inicio del TAR en el mismo día de la prueba diagnóstica ocurrió en 864 pacientes (89%), de los cuales 628 recién diagnosticados (65%). Más del 80% de las personas que recibieron la prueba en los departamentos de salud maternoinfantil inició el TAR el mismo día. En las 144 personas inscritas al servicio de atención que no iniciaron tratamiento (16%), la principal razón fue una transferencia a otra unidad en 102 de ellas (71%). La mayoría de los pacientes que recibían TAR (90%) permanecía en los servicios de atención a los 3 meses y la mayor parte de los pacientes restantes correspondía a las transferencias a otra unidad.Conclusión: La introducción de la estrategia 'Análisis y Tratamiento' fue factible y eficaz para conseguir que las personas con una infección reciente iniciaran pronto el TAR. Se precisan nuevas investigaciones que permitan comprender mejor los procesos, los beneficios y los eventuales riesgos.

Has the utilisation of Xpert® MTB/RIF in Manicaland Province, Zimbabwe, improved with new guidance on whom to test?

Setting: Manicaland Province, Zimbabwe. Objectives: To compare the utilisation and results of deploying Xpert® MTB/RIF in 13 (one provincial, six district and six rural) hospitals between January and June 2016, when Xpert was recommended only for those with presumptive multidrug-resistant tuberculosis (MDR-TB) and coinfection with human immunodeficiency virus (HIV), and between January and June 2017, when Xpert was recommended for all presumptive TB patients. Design: This was a cross-sectional study. Results: Xpert assays averaged 759 monthly in 2016 and 1430 monthly in 2017 (88% increase). Utilisation of Xpert averaged 22% monthly in 2016 and 42% in 2017 (88% increase). In 2017, utilisation of Xpert was significantly higher in provincial (82%) than in district (51%) and rural (26%) hospitals (P < 0.001). The proportion of successful assays that detected TB decreased significantly from 13% in 2016 to 7% in 2017 (a 46% decrease, P < 0.001); this phenomenon was observed in all types of hospital. The proportion of persons detected with rifampicin-resistant TB was similar between hospitals (4% in 2016 and 3% in 2017). The proportion of registered TB cases with bacteriological confirmation increased from 48% in 2016 to 53% in 2017 (P = 0.04). Conclusion: Xpert use in all presumptive TB patients led to a significant increase in assay numbers and utilisation of Xpert instruments, resulting in more bacteriological confirmation of cases.

Contexte : Province de Manicaland, Zimbabwe.Objectif : Comparer l'utilisation et les résultats du déploiement de l'Xpert® MTB/RIF dans 13 hôpitaux (1 provincial, 6 de district et 6 ruraux) entre janvier et juin 2016, quand l'Xpert a été recommandé seulement pour les patients ayant une présomption de la tuberculose (TB) multirésistante et une coinfection par le virus de l'immunodéficience humaine, et de janvier à juin 2017, quand l'Xpert a été recommandé pour tous les patients présumés TB.Schéma : Etude transversale.Résultats : Le nombre moyen de tests Xpert a été de 759 par mois en 2016 et de 1430 par mois en 2017 (augmentation de 88%). L'utilisation de l'instrument a été d'environ 22% par mois en 2016 et de 42% en 2017 (augmentation de 88%). En 2017, l'utilisation de l'instrument a été significativement plus élevée dans l'hôpital provincial (82%) comparé aux hôpitaux de district et ruraux (51% contre 26% ; P < 0,001). La proportion de succès des tests qui ont détecté une TB a significativement diminué de 13% en 2016 à 7% en 2017 (diminution de 46% ; P < 0,001) ; ceci a été observé dans tous les types d'hôpitaux. Les proportions de TB résistantes à la rifampicine ont été similaires entre les hôpitaux (4% en 2016 et 3% en 2017). La proportion des cas de TB enregistrés avec une confirmation bactériologique a augmenté de 48% en 2016 à 53% en 2017 (P = 0,04).Conclusion : L'utilisation du Xpert pour tous les patients présumés TB, les nombres de tests et l'utilisation de l'instrument Xpert ont significativement augmenté, aboutissant à davantage de confirmation bactériologique des cas.

Marco de referencia: La provincia de Manicaland, en Zimbabwe.Objetivos: Comparar la utilización de los dispositivos Xpert® MTB/RIF y los resultados de su despliegue en 13 hospitales (1 de provincia, 6 distritales y 6 rurales) durante dos períodos: de enero a junio del 2016, cuando se recomendaba la prueba Xpert solo en los casos de presunción de tuberculosis (TB) multirresistente y coinfección por el virus de la inmunodeficiencia humana, y de enero a junio del 2017, cuando se recomendaba la prueba Xpert en todos los pacientes con presunción de TB.Objetivos: Fue este un estudio transversal.Resultados: El promedio mensual de pruebas Xpert fue 759 en el 2016 y 1430 en el 2017 (un aumento del 88%). El porcentaje de utilización de los dispositivos Xpert fue en promedio 22% mensual en el 2016 y 42% en el 2017 (un aumento del 88%). En el 2017, la utilización de los dispositivos Xpert fue significativamente mayor en los hospitales de provincia (82%) comparados con los hospitales distritales y los rurales (51% contra 26%; P < 0,001). La proporción de análisis eficaces que detectaban la TB disminuyó de manera notable de 13% en el 2016 a 7% en el 2017 (una disminución del 46%; P < 0,001); esta situación se observó en todos los tipos de hospitales. La proporción de casos detectados de TB con resistencia a rifampicina fue equivalente en todos los hospitales (4% en el 2016 y 3% en el 2017). La proporción de casos de TB con confirmación bacteriológica registrados aumentó del 48% en el 2016 al 53% en el 2017 (P = 0,04).Conclusión: Al utilizar la prueba Xpert en todos los pacientes con presunción clínica de TB se aumentó considerablemente el número de pruebas y la utilización de los dispositivos Xpert, lo cual ha dado lugar a una mayor proporción de casos con confirmación bacteriológica.