Chronic Respiratory Symptoms and Lung Abnormalities Among People With a History of Tuberculosis in Uganda: A National Survey.

BACKGROUND: People with pulmonary tuberculosis are at risk of developing chronic respiratory disorders due to residual lung damage. To date, the scope of the problem in high-burden tuberculosis countries is relatively unknown. METHODS: Chronic respiratory symptoms (cough and phlegm lasting >2 weeks) and radiological lung abnormalities were compared between adults with and without a history of tuberculosis among the general population of Uganda. Multivariable regression models were used to estimate odds ratios (ORs) with adjustment for age, gender, smoking, education, setting, and region. Random effects models accounted for village clustering effect. RESULTS: Of 45293 invited people from 70 villages, 41154 (90.9%) participated in the survey. A total of 798 had a history of tuberculosis and, among them, 16% had respiratory symptoms and 41% X-ray abnormalities. Adjusted ORs showed strong evidence for individuals with a history of tuberculosis having increased risk of respiratory symptoms (OR, 4.02; 95% confidence interval [CI], 3.25-4.96) and X-ray abnormalities (OR, 17.52; 95% CI, 14.76-20.79), attributing 6% and 24% of the respective population risks. CONCLUSIONS: In Uganda, a history of tuberculosis was a strong predictor of respiratory symptoms and lung abnormalities, before older age and smoking. Eliminating tuberculosis disease could reduce the prevalence of chronic respiratory symptoms as much as eliminating smoking.

Theory-Informed Design of a Tailored Strategy for Implementing Household TB Contact Investigation in Uganda.

Since 2012, the World Health Organization has recommended household contact investigation as an evidence-based intervention to find and treat individuals with active tuberculosis (TB), the most common infectious cause of death worldwide after COVID-19. Unfortunately, uptake of this recommendation has been suboptimal in low- and middle-income countries, where the majority of affected individuals reside, and little is known about how to effectively deliver this service. Therefore, we undertook a systematic process to design a novel, theory-informed implementation strategy to promote uptake of contact investigation in Uganda, using the COM-B (Capability-Opportunity-Motivation-Behavior) model and the Behavior Change Wheel (BCW) framework. We systematically engaged national, clinic-, and community-based stakeholders and collectively re-examined the results of our own formative, parallel mixed-methods studies. We identified three core behaviors within contact investigation that we wished to change, and multiple antecedents (i.e., barriers and facilitators) of those behaviors. The BCW framework helped identify multiple intervention functions targeted to these antecedents, as well as several policies that could potentially enhance the effectiveness of those interventions. Finally, we identified multiple behavior change techniques and policies that we incorporated into a multi-component implementation strategy, which we compared to usual care in a household cluster-randomized trial. We introduced some components in both arms, including those designed to facilitate initial uptake of contact investigation, with improvement relative to historical controls. Other components that we introduced to facilitate completion of TB evaluation-home-based TB-HIV evaluation and follow-up text messaging-returned negative results due to implementation failures. In summary, the Behavior Change Wheel framework provided a feasible and transparent approach to designing a theory-informed implementation strategy. Future studies should explore the use of experimental methods such as micro-randomized trials to identify the most active components of implementation strategies, as well as more creative and entrepreneurial methods such as human-centered design to better adapt the forms and fit of implementation strategies to end users.

Anti-retroviral therapy scale-up and its impact on sex-stratified tuberculosis notification trends in Uganda.

INTRODUCTION: In order to end the tuberculosis (TB) epidemic by 2035, countries must achieve a 10% annual decline in tuberculosis incidence rates by 2025. Provision of antiretroviral therapy (ART) has been associated with population level decreases in TB notification rates. We aimed to assess whether the progressive scale-up of ART provision over the past nine years has had an effect on population level trends of TB notification in Uganda stratified by sex and HIV status. METHODS: The study area consisted of Kampala and eight surrounding districts. Annual TB notifications and mid-year populations were used to calculate notification rates per 100,000 population from the study area. Numbers alive and retained on ART were used to calculate ART coverage, overall and by sex. TB notification rates (TBNRs) overall and stratified by sex and HIV status were calculated for the period 2009 to 2017. Trends in TBNRs before and after rollout of universal ART for pregnant women in 2013 were examined using Poisson regression models. To gain insight into the trends in CD4+ T-cell counts at ART initiation over the study period, we performed a sub analysis of patient level data from the Infectious Diseases Institute clinic. RESULTS: From 2009 to 2017, ART coverage increased by 27.6% among men and by 35.4% among women. TBNRs declined during the same period. Overall, the average annual percentage decline in TBNRs was -3.5% (95%CI -3.7% to -3.3%), (-2.3% (95%CI -2.6% to -1.9%) in men and -5.4% (95%CI -5.7% to -5.0%) in women). ART coverage increased after 2013 but this was not associated with an accelerated decline in overall TBNRs among HIV-positive persons -3.6% before 2013 and -5.2% after 2013; p = 0.33. The proportion of patients initiating ART with CD4+ T-cell count ≤ 200 cells/mL did not decrease significantly after 2013 (42.2% to 32.2%, p = 0.05). CONCLUSIONS: Although ART scale-up was temporally associated with a decline in TB notification rates, the achieved rates of decline are below those required to achieve the End TB Targets. Additional investments in tuberculosis control should include efforts to promote earlier care seeking and ART initiation among HIV-positive persons.