Preparedness of outpatient health facilities for ambulatory treatment with all-oral short DR-TB treatment regimens in Zhytomyr, Ukraine: a cross-sectional study.

BACKGROUND: Ukraine has a high burden of drug-resistant tuberculosis (DR-TB). Mental health problems, including alcohol use disorder, are common co-morbidities. One in five DR-TB patients has human immunodeficiency virus (HIV). As part of health reform, the country is moving from inpatient care to ambulatory primary care for tuberculosis (TB). In Zhytomyr oblast, Médecins Sans Frontières (MSF) is supporting care for DR-TB patients on all-oral short DR-TB regimens. This study describes the preparedness of ambulatory care facilities in Zhytomyr oblast, Ukraine, to provide good quality ambulatory care. METHODS: This is a retrospective analysis of routinely collected programme data. Before discharge of every patient from the hospital, MSF teams assess services available at outpatient facilities using a standardised questionnaire. The assessment evaluates access, human resources, availability of medicines, infection control measures, laboratory and diagnostic services, and psychosocial support. RESULTS: We visited 68 outpatient facilities in 22 districts between June 2018 and September 2019. Twenty-seven health posts, 24 TB-units, 13 ambulatories, two family doctors and one polyclinic, serving 30% of DR-TB patients in the oblast by September 2019, were included. All facilities provided directly observed treatment, but only seven (10%) provided weekend-services. All facilities had at least one medical staff member, but TB-training was insufficient and mostly limited to TB-doctors. TB-treatment and adequate storage space were available in all facilities, but only five (8%) had ancillary medicines. HIV-positive patients had to visit a separate facility to access HIV-care. Personal protective equipment was unavailable in 32 (55%) facilities. Basic laboratory services were available in TB-units, but only four (17%) performed audiometry. Only ten (42%) TB-units had psychosocial support available, and nine (38%) offered psychiatric support. CONCLUSION: Outpatient facilities in Zhytomyr oblast are not yet prepared to provide comprehensive care for DR-TB patients. Capacity of all facilities needs strengthening with trainings, infection control measures and infrastructure. Integration of psychosocial services, treatment of co-morbidities and adverse events at the same facility are essential for successful decentralisation. The health reform is an opportunity to establish quality, patient-centred care.

Mental health interventions for rifampicin-resistant tuberculosis patients with alcohol use disorders, Zhytomyr, Ukraine.

INTRODUCTION: Despite concerted efforts, Ukraine is challenged by increasing rates of multidrug and rifampicin-resistant tuberculosis (MDR/RR-TB) comorbid with alcohol use disorder (AUD). This study describes a cohort of RR-TB patients with high alcohol consumption treated in MSF Zhytomyr Project, Ukraine. METHODOLOGY: We used programmatic data for 73 RR-TB patients screened with the AUD Identification Test March-July 2019 and followed-up for culture conversion/TB treatment outcome till 31 January 2020. We described socio-demographic, behavioral, and clinical characteristics, the level of depressive symptoms, and TB treatment outcomes in three groups: 1) patients with AUD who received mental health interventions (MHI); 2) patients with AUD who did not receive MHI; 3) patients with no AUD. We also found three potential contributors to declining to receive MHI. RESULTS: Main characteristics of the study groups did not differ substantially. Those receiving MHI (mean: nine sessions) were rated for alcohol consumption as 'hazardous' (41%), 'harmful' (43%) and 'dependence' (36%) and had higher depression scores versus the second (p=0.009) and third (p=0.095) groups at baseline. Depressive symptoms declined at 9-month follow-up for all patients. Culture conversion was seen at 77%, 73%, and 83% for each group respectively. We also found three reasons for declining from MHI. CONCLUSIONS: We detected little differences across the groups. However, our study cohort demonstrated substantially higher adherence rates, culture conversion and reduction of depressive symptoms than reported globally. We recommend further research on the effectiveness of MHI in changing the drinking habits, quality of life and/or TB treatment outcomes of patients with AUD.