Monitoring Therapy Compliance of Tuberculosis Patients by using Video-Enabled Electronic Devices.

A recent innovation to help patients adhere to daily tuberculosis (TB) treatment over many months is video (or virtually) observed therapy (VOT). VOT is becoming increasingly feasible as mobile telephone applications and tablet computers become more widely available. Studies of the effectiveness of VOT in improving TB patient outcomes are being conducted.

High risk and rapid appearance of multidrug resistance during tuberculosis treatment in Moldova.

Multidrug-resistant tuberculosis (MDR-TB) is a serious problem in the former Soviet Union and may appear during TB treatment. We aimed to estimate the prevalence of, timing of and factors associated with MDR-TB diagnosis during TB treatment in Moldova, which was part of the former Soviet Union. We analysed data on 3 754 confirmed non-MDR-TB cases (between January 1, 2007 and December 31, 2010) in the Moldovan TB surveillance database, where patients provided sputum specimens for drug-susceptibility testing, multiple times, during treatment. We estimated the percentage of individuals with confirmed baseline non-MDR-TB that were diagnosed with MDR-TB during treatment, documented the time at which MDR-TB was diagnosed, and used a failure-time model to identify factors associated with MDR-TB diagnosis. Between 7.2% and 9.2% of initially non-MDR-TB cases were diagnosed with MDR-TB during treatment. Half of these MDR-TB diagnoses occurred with 3 months of the initial diagnosis. An increased MDR-TB risk during treatment was associated with baseline resistance to first-line TB drugs (linear increase in risk per additional drug), previous incarceration and HIV co-infection. MDR can appear rapidly during TB treatment. Policy considerations should emphasise management during early treatment by increasing ambulatory TB treatment to prevent nosocomial transmission, and ensuring universal rapid diagnostics access to prevent acquisition and transmission of drug resistance.

Assessing spatial heterogeneity of multidrug-resistant tuberculosis in a high-burden country.

Multidrug-resistant tuberculosis (MDR-TB) is a major concern in countries of the former Soviet Union. The reported risk of resistance among tuberculosis (TB) cases in the Republic of Moldova is among the highest in the world. We aimed to produce high-resolution spatial maps of MDR-TB risk and burden in this setting. We analysed national TB surveillance data collected between 2007 and 2010 in Moldova. High drug susceptibility testing coverage and detailed location data permitted identification of subregional areas of higher MDR-TB risk. We investigated whether the distribution of cases with MDR-TB risk factors could explain this observed spatial variation in MDR-TB. 3447 MDR-TB cases were notified during this period; 24% of new and 62% of previously treated patients had MDR-TB. Nationally, the estimated annual MDR-TB incidence was 54 cases per 100 000 persons and >1000 cases per 100 000 persons within penitentiaries. We identified substantial geographical variation in MDR-TB burden and hotspots of MDR-TB. Locations with a higher percentage of previously incarcerated TB cases were at greater risk of being MDR-TB hotspots. Spatial analyses revealed striking geographical heterogeneity of MDR-TB. Methods to identify locations of high MDR-TB risk and burden should allow for better resource allocation and more appropriate targeting of studies to understand local mechanisms driving resistance.

Building the Evidence for a Rights-Based, People-Centered, Gender-Transformative Tuberculosis Response: An Analysis of the Stop TB Partnership Community, Rights, and Gender Tuberculosis Assessment.

The global tuberculosis (TB) response has undergone a transformation in recent years. Calls for a paradigm shift have inspired a new focus on the importance of communities, human rights, and gender in the response. This focus has led to new approaches and innovative tools to fight an age-old disease that still affects millions each year. Notable among these tools is the Stop TB Partnership's community, rights, and gender (CRG) assessment. TB civil society and community groups, in partnership with national TB programs and others, have conducted the CRG assessment in 20 countries across four regions. Using the normative right to health framework, this article analyzes the evidence base generated by this assessment to understand the communities, legal environments, and gender dynamics at the heart of the epidemic. It describes an array of issues revealed by the assessment findings, including limited access to health services, disease-based discrimination, lack of privacy protections, and the impact of patriarchal norms on women affected by TB. Finally, this article considers how to strengthen the CRG assessment and how countries affected by TB and their donors and technical partners can leverage its findings in line with the Sustainable Development Goals and the political declaration from the first-ever United Nations High-Level Meeting on Tuberculosis.

Characterizing and Measuring Tuberculosis Stigma in the Community: A Mixed-Methods Study in Cambodia.

BACKGROUND: Stigma is a significant barrier to healthcare and a factor that drives the global burden of tuberculosis (TB). However, there is a scarcity of information on TB stigma in developing countries. We aimed to characterize, measure, and explore the determinants of TB stigma among people with TB in Cambodia. METHODS: We conducted a mixed-methods study between February and August 2019 using a triangulation convergent design-a cross-sectional survey (n = 730) and nested in-depth interviews (n = 31) among people with TB. Quantitative data were analyzed using descriptive statistics and generalized linear regression models. Qualitative transcripts were thematically analyzed. RESULTS: A total of 56% and 51% of participants experienced self-stigma and perceived stigma by the community, respectively. We found rural dwellers, knowledge of how TB is transmitted, and knowledge that anybody can get TB were associated with higher levels of self-stigma and perceived stigma by the community. Higher scores on knowledge of TB symptoms were inversely associated with both self-stigma and community stigma. Thematic analyses revealed accounts of experienced stigma, acts of intentional distancing and hiding TB diagnosis from others, and feelings of embarrassment and shame. CONCLUSIONS: Tuberculosis stigma was prevalent, suggesting a need for the incorporation of stigma-reduction strategies in the national TB responses. These strategies should be contextualized and developed through community engagement. Future research should continue to measure the levels and dimensions of TB stigma among people with TB through behavioral surveillance using standardized tools.

Palliative Care in Moldova.

The article describes the important steps of palliative care development in Moldova, the current status, main achievements and challenges to be addressed in the future. It covers background information, policy development, medicines access and availability, education, and training, as well as services' provision. Palliative care development in Moldova registered real progress in spite of frequent political changes at governmental levels and difficulties to ensure the continuity of the development process during the last 10 years. However, the unmet need for palliative care for patients with life-limiting illnesses from different disease and age groups remains high. Further effort is needed to increase the availability and access to opioid analgesics and other essential palliative care medications. Government commitment and support, together with adequate funding, trained and educated health care professionals, and easy access to and availability of medicines, are essential to ensure the successful implementation of palliative care services nationwide, and to deliver the most appropriate qualitative palliative care for patients. To speed up palliative care development, a national strategy on palliative care development should be considered. The authors took part and continue to be involved in different ways in palliative care development in the country.

Increasing tuberculosis case detection: lessons from the Republic of Moldova.

The Republic of Moldova undertook reforms in tuberculosis (TB) control and health care consistent with international recommendations and advanced towards the global target for case detection. The number of TB cases notified increased overall by 50% during 2001-2005. Expansion of the DOTS strategy and full coverage coincided with a greater role for primary health care (PHC) in TB control and the advent of national insurance for TB diagnosis and treatment. These developments and improvements in laboratories, surveillance, medical personnel skills, and public awareness contributed to increased case detection. The Republic of Moldova addressed both demand and supply sides in these efforts. It increased effective demand for TB services by dispersing diagnostic capability, instituting financing mechanisms and saturating the public with information on symptoms, transmission and treatment. It increased the supply of TB services by upgrading the laboratory network, revamping surveillance and training practitioners. The Republic of Moldova's experience offers lessons for other countries: TB-PHC integration allowed more suspect cases to be diagnosed at nearby PHC clinics, contributing to more cases being notified. Innovative TB communications reached the general public, vulnerable groups, practitioners and the media. TB control projects built on each other and national coordination mechanisms served to identify funding for the most pressing needs. There are challenges remaining for TB control in the Republic of Moldova, not least the stable treatment success rate, but the country can list valuable lessons and achievements.