Prior tuberculosis, radiographic lung abnormalities and prevalent diabetes in rural South Africa.

BACKGROUND: Growing evidence suggests that chronic inflammation caused by tuberculosis (TB) may increase the incidence of diabetes. However, the relationship between post-TB pulmonary abnormalities and diabetes has not been well characterized. METHODS: We analyzed data from a cross-sectional study in KwaZulu-Natal, South Africa, of people 15 years and older who underwent chest X-ray and diabetes screening with hemoglobin A1c testing. The analytic sample was restricted to persons with prior TB, defined by either (1) a self-reported history of TB treatment, (2) radiologist-confirmed prior TB on chest radiography, and (3) a negative sputum culture and GeneXpert. Chest X-rays of all participants were evaluated by the study radiologist to determine the presence of TB lung abnormalities. To assess the relationships between our outcome of interest, prevalent diabetes (HBA1c ≥6.5%), and our exposure of interest, chest X-ray abnormalities, we fitted logistic regression models adjusted for potential clinical and demographic confounders. In secondary analyses, we used the computer-aided detection system CAD4TB, which scores X-rays from 10 to 100 for detection of TB disease, as our exposure interest, and repeated analyses with a comparator group that had no history of TB disease. RESULTS: In the analytic cohort of people with prior TB (n = 3,276), approximately two-thirds (64.9%) were women, and the average age was 50.8 years (SD 17.4). The prevalence of diabetes was 10.9%, and 53.0% of people were living with HIV. In univariate analyses, there was no association between diabetes prevalence and radiologist chest X-ray abnormalities (OR 1.23, 95%CI 0.95-1.58). In multivariate analyses, the presence of pulmonary abnormalities was associated with an 29% reduction in the odds of prevalent diabetes (aOR 0.71, 95%CI 0.53-0.97, p = 0.030). A similar inverse relationship was observed for diabetes with each 10-unit increase in the CAD4TB chest X-ray scores among people with prior TB (aOR 0.92, 95%CI 0.87-0.97; p = 0.002), but this relationship was less pronounced in the no TB comparator group (aOR 0.96, 95%CI 0.94-0.99). CONCLUSIONS: Among people with prior TB, pulmonary abnormalities on digital chest X-ray are inversely associated with prevalent diabetes. The severity of radiographic post-TB lung disease does not appear to be a determinant of diabetes in this South African population.

Building an Infectious Disease Diversity, Equity, and Antiracism (ID2EA) Curriculum: A Single Center's Experience and Reflections.

In response to longstanding healthcare inequities unmasked by the Coronavirus Disease 2019 pandemic, the infectious diseases (ID) section at the Yale School of Medicine designed and implemented a pilot curriculum integrating Infectious Disease Diversity, Equity, and Antiracism (ID2EA) into ID educational training and measured program outcomes. We herein describe a mixed-methods assessment of section members on whether the ID2EA curriculum affected their beliefs and behaviors regarding racism and healthcare inequities. Participants rated the curriculum as useful (92% averaging across sessions) and effective in achieving stated learning objectives (89% averaging across sessions), including fostering understanding of how inequities and racism are linked to health disparities and identifying strategies to effectively deal with racism and inequities. Despite limitations in response rates and assessment of longer-term behavioral change, this work demonstrates that training in diversity, equity, and antiracism can be successfully integrated into ID physicians' educational activities and affect physicians' perspectives on these topics.

Prioritizing persons deprived of liberty in global guidelines for tuberculosis preventive treatment.

In this Policy Forum piece, Aditya Narayan and colleagues discuss the challenges and opportunities for tuberculosis preventive treatment in carceral settings.

Integrated Care Models: HIV and Substance Use.

PURPOSE OF REVIEW: Behaviors and practices associated with substance use contribute to lack of HIV virologic suppression and onward transmission. In the USA, many recent HIV outbreaks have been connected with substance use. Evidence-based strategies for integrating care of those at risk for and living with HIV and who use substances continue to evolve. This review, based on scientific and medical literature through March 2023, provides an overview and evaluation of initiatives for integrated care aimed to serve patients at risk for and with HIV and a substance use disorder. RECENT FINDINGS: Integrated care services can improve health outcomes for patients at risk for and with HIV and a substance use disorder; for instance, treatment for an opioid use disorder can help improve HIV viral suppression. Brick-and-mortar facilities can provide successful care integration with appropriate clinic leadership to support multidisciplinary care teams, up-to-date provider training, and sufficient pharmacy stock for substance use treatment. Delivering healthcare services to communities (e.g., mobile healthcare clinics and pharmacies, telehealth) may prove to be an effective way to provide integrated services for those with or at risk of HIV and substance use disorders. Incorporating technology (e.g., mobile phone applications) may facilitate integrated care. Other venues, including harm reduction programs and carceral settings, should be targets for integrated services. Venues providing healthcare should invest in integrated care and support legislation that increases access to services related to HIV and substance use.

Treatment System Adaptations during War: Lessons from Ukrainian Addiction Treatment Providers.

Background: The war in Ukraine has posed significant challenges to the healthcare system. This paper draws upon expert consultations, held between December 2022 and February 2023, focused on HIV/AIDS, addiction, and mental health service delivery during the first year of this war, and following the Global Mental Health Humanitarian Coalition panel discussion in May 2022. Objectives: This commentary presents the experiences of frontline healthcare workers in Ukraine, challenges, and local adaptations to meet the increased mental health needs of healthcare providers. We aimed to document the adaptations made in the addiction healthcare system and to acknowledge the changes in vulnerabilities and lessons learned. Results: Burnout among healthcare providers delivering addiction, HIV/AIDS and mental health services became more visible after the second half of 2022. Challenges included increased workload, contextual threats, lack of job relocation strategies, and money-follow-the-patient policies. Recommendations: The lessons from the first year of war in Ukraine hold significant generalizability to other contexts. These include enabling bottom-up approaches to tailoring services and allowing healthcare providers to respond to the dynamics of war in an effective and active manner. Other recommendations include departmental-specific resources and strategies, particularly as vulnerable groups and challenges are unstable in humanitarian contexts. Conclusions: Globally and in Ukraine, healthcare workers need more than applause. Along with monetary incentives, other strategies to prevent burnout, ensure sustainable capacity building, job relocation opportunities, and bespoke adaptations are imperative to protect healthcare providers' wellbeing and overall public health.

Community health workers can be trained to identify patients eligible for tuberculosis preventive therapy, but encounter barriers to programme implementation in KwaZulu-Natal, South Africa.

Tuberculosis (TB) remains one of the top 10 causes of death worldwide, ranking as the leading cause of death from infectious disease, above HIV and AIDS. South Africa has the sixth highest TB incidence rate in the world and the world's largest HIV epidemic. This study sought to demonstrate the feasibility of community health workers (CHWs) contributing to the implementation of tuberculosis preventive therapy (TPT) among people living with HIV and AIDS. Twelve community health workers were trained to test for communicable and non-communicable diseases and screen for TPT eligibility. They visited a select number of homes monthly to conduct screening for HIV, TB and non-communicable diseases. We recorded screening results, rates of referral for TPT, linkage to care - defined as being seen in the clinic for TPT - and treatment initiation. Among the 1 279 community members screened, 248 were identified as living with HIV, 99 (39.9%) individuals were identified as eligible for TPT, and 46 (46.5%) were referred to care. Among those referred, the median age was 39 (IQR 30-48) and 29 (63%) linked to care; 11 (37.9%) of those linked subsequently initiated treatment. In rural South Africa, it is feasible to train CHWs to identify and refer patients eligible for TPT, but losses occurred at each step of the cascade. CHWs can facilitate TPT implementation, although further implementation research exploring and addressing barriers to TPT (on an individual, provider and systems level) should be prioritised to optimise their role in rural resource-limited settings.

"We've Got Our Own Beliefs, Attitudes, Myths": A Mixed Methods Assessment of Rural South African Health Care Workers' Knowledge of and Attitudes Towards PrEP Implementation.

South Africa maintains the world's largest HIV prevalence, accounting for 20.4% of people living with HIV internationally. HIV Pre-exposure prophylaxis (PrEP) has demonstrated efficacy; however, there is limited data on PrEP implementation in South Africa, particularly in rural areas. Using grounded theory analysis of semi-structured interviews and exploratory factor analyses of structured surveys, this mixed methods study examines healthcare workers' (HCWs)' beliefs about their patients and the likelihood of PrEP uptake in their communities. The disproportionate burden of HIV among Black South Africans is linked to the legacy of apartheid and resulting disparities in wealth and employment. HCWs in our study emphasized the importance of addressing these structural barriers, including increased travel burden among men in the community looking for work, poor transportation infrastructure, and limited numbers of highly skilled clinical staff in their rural community. HCWs also espoused a vision of PrEP that prioritizes women due to perceived constraints on their sexual agency, and that minimizes the impact of HIV-related stigma on PrEP implementation. However, HCWs' additional concerns for risk compensation may reflect dominant social mores around sexual behavior. In recognition of HCWs' role as both informants and community members, implementation scientists should invite local HCWs to partner as early as the priority-setting stage for PrEP interventions. Inviting leadership from local HCWs may increase the likelihood of delivery plans that account for unique local context and structural barriers researchers may otherwise struggle to uncover.

Mobility and structural barriers in rural South Africa contribute to loss to follow up from HIV care.

Retention in HIV care is crucial to sustaining viral load suppression, and reducing HIV transmission, yet loss to follow-up (LTFU) in South Africa remains substantial. We conducted a mixed methods evaluation in rural South Africa to characterize ART disengagement in neglected rural settings. Using convenience sampling, surveys were completed by 102 PLWH who disengaged from ART (minimum 90 days) and subsequently resumed care. A subset (n = 60) completed individual in-depth interviews. Median duration of ART discontinuation was 9 months (IQR 4-22). Participants had HIV knowledge gaps regarding HIV transmission and increased risk of tuberculosis. The major contributors to LTFU were mobility and structural barriers. PLWH traveled for an urgent family need or employment, and were not able to collect ART while away. Structural barriers included inability to access care, due to lack of financial resources to reach distant clinics. Other factors included dissatisfaction with care, pill fatigue, lack of social support, and stigma. Illness was the major precipitant of returning to care. Mobility and structural barriers impede longitudinal HIV care in rural South Africa, threatening the gains made from expanded ART access. To achieve 90-90-90, future interventions, including emphasis on patient centered care, must address barriers relevant to rural settings.

Title: Expansion of a national differentiated service delivery model to support people living with HIV and other chronic conditions in South Africa: a descriptive analysis.

BACKGROUND: South Africa is home to 7.7 million people living with HIV and supports the largest antiretroviral therapy (ART) program worldwide. Despite global investment in HIV service delivery and the parallel challenge of non-communicable diseases (NCDs), there are few examples of integrated programs addressing both HIV and NCDs through differentiated service delivery. In 2014, the National Department of Health (NDoH) of South Africa launched the Central Chronic Medicines Dispensing and Distribution (CCMDD) program to provide patients who have chronic diseases, including HIV, with alternative access to medications via community-based pick-up points. This study describes the expansion of CCMDD toward national scale. METHODS: Yale monitors CCMDD expansion as part of its mixed methods evaluation of Project Last Mile, a national technical support partner for CCMDD since 2016. From March 2016 through October 2019, cumulative weekly data on CCMDD uptake [patients enrolled, facilities registered, pick-up points contracted], type of medication provided [ART only; NCD only; and ART-NCD] and collection sites preferred by patients [external pick-up points; adherence/outreach clubs; or facility-based fast lanes], were extracted for descriptive, longitudinal analysis. RESULTS: As of October 2019, 3,436 health facilities were registered with CCMDD across 46 health districts (88 % of South Africa's districts), and 2,037 external pick-up points had been contracted by the NDoH. A total of 2,069,039 patients were actively serviced through CCMDD, a significant increase since 2018 (p < 0.001), including 76 % collecting ART [64 % ART only, 12 % ART plus NCD/comorbidities] and 479,120 [24 %] collecting medications for chronic diseases only. Further, 734,005 (35 %) of patients were collecting from contracted, external pick-up points, a 73 % increase in patient volume from 2018. DISCUSSION: This longitudinal description of CCMDD provides an example of growth of a national differentiated service delivery model that integrates management of HIV and noncommunicable diseases. This study demonstrates the success of the program in engaging patients irrespective of their chronic condition, which bodes well for the potential of the program to address the rising burden of both HIV and NCDs in South Africa. CONCLUSIONS: The CCMDD program expansion signals the potential for a differentiated service delivery strategy in resource-limited settings that can be agnostic of the patients chronic disease condition.

The Lived Experience of a Newly Diagnosed Older Person With HIV in Ukraine.

Low- and middle-income countries are home to 80% of older people with HIV (OPWH). Ukrainian OPWH experience higher mortality and decreased antiretroviral therapy (ART) initiation than younger patients, but there is little data examining OPWH's perspectives around new diagnosis and impact on care. In this study, we examined accounts of 30 newly diagnosed OPWH in Ukraine, exploring challenges faced in the peri-diagnosis period. Themes emerged representing the longitudinal coping process: OPWH (1) viewed themselves as low risk before diagnosis; (2) experienced HIV diagnosis as a traumatic event challenging their self-image; (3) used disclosure to seek support among a small circle of family, friends, or health care providers; (4) avoided disclosure to outsiders including primary care providers for fears of stigma and breaches in confidentiality; (5) viewed age as an asset; and (6) used HIV diagnosis as starting point for growth. These findings highlight the need for age-specific programming to increase HIV knowledge and coping, increase screening, and improve long-term planning.

Mobile Device Usage by Gender Among High-Risk HIV Individuals in a Rural, Resource-Limited Setting.

Background: Mobile health (mHealth) is a promising tool to deliver healthcare interventions to underserved populations. We characterized the use of mobile devices in rural KwaZulu-Natal, South Africa to tailor mHealth interventions for people living with HIV and at risk for acquiring HIV in the middle-income country. Methods: We surveyed participants in community settings and offered free HIV counseling and testing. Participants self-reported their gender, age, relationship, and employment status, receipt of monthly grant, condomless sex frequency, and circumcision status (if male). Outcomes included cell phone and smartphone ownership, private data access, health information seeking, and willingness to receive healthcare messages. We performed multivariable logistic regression to assess the relationship between demographic factors and outcomes. Results: Although only 10% of the 788 individuals surveyed used the phone to seek health information, 93% of cell phone owners were willing to receive healthcare messages. Being young, female, employed, and in a relationship were associated with cell phone ownership. Smartphone owners were more likely to be young, female, and employed. Participants reporting condomless sex or lack of circumcision were significantly less likely to have private data access or to purchase data. Conclusions: mHealth interventions should be feasible in rural KwaZulu-Natal, though differ by gender. As women are more likely to own smartphones, smartphone-based mHealth interventions specifically geared to prevent the acquisition of or to support the care of HIV in young women in KwaZulu-Natal may be feasible. mHealth interventions encouraging condom use and medical male circumcision should consider the use of nonsmartphone short message service and be attuned to mobile data limitations-especially when targeting men.

Social Support is Key to Retention in Care during Covid-19 Pandemic among Older People with HIV and Substance Use Disorders in Ukraine.

BACKGROUND: Older people with human immunodeficiency virus - HIV (OPWH) defined as ≥50 years old account for a growing proportion of newly diagnosed infections in Ukraine (16% in 2018), but the prevalence of substance use disorder among OPWH in Ukraine remains unknown. Ukraine responded to the Covid-19 pandemic with a comprehensive lockdown in late March 2020. Objectives: We conducted a phone survey among 123 OPWH with substance use disorders (SUD) in Kyiv in May 2020 to learn if these older adults may continue HIV and SUD therapy while coping with the Covid-19 pandemic. Results: Data from the survey demonstrated that while OPWH with SUD maintained HIV and SUD therapy throughout Covid-19 lockdown, social support is critical to avoiding treatment interruption for OPWH with SUD. Conclusions/Importance: During reopening, reduction of support may lead to OPWH feeling even more isolated. Post-Covid-19 pharmacological approaches to SUD treatment without social support are like vehicles without gas. The research agenda for OPWH patients with SUD going forward must include determining the type of telehealth support that will be optimally effective to retain OPWH including people who inject drugs (PWID), provision of support by lay health workers, and cost-effectiveness of such interventions. The lessons learned may be relevant to other countries as well.

"It's about my life": facilitators of and barriers to isoniazid preventive therapy completion among people living with HIV in rural South Africa.

Despite the recent rollout of Isoniazid Preventive Therapy (IPT) to prevent TB in people living with HIV in South Africa, adherence and completion rates are low. To explore barriers to IPT completion in rural KwaZulu-Natal, South Africa, we conducted individual semi-structured interviews among 30 HIV patients who had completed or defaulted IPT. Interview transcripts were analyzed according to the framework method of qualitative analysis. Facilitators of IPT completion included knowledge of TB and IPT, accepting one's HIV diagnosis, viewing IPT as similar to antiretroviral therapy, having social support in the community and the clinic, trust in the healthcare system, and desire for health preservation. Barriers included misunderstanding of IPT's preventive role in the absence of symptoms, inefficient health service delivery, ineffective communication with healthcare workers, financial burden of transport to clinic and lost wages, and competing priorities. HIV-related stigma was not identified as a significant barrier to IPT completion, and participants felt confident in their ability to manage stigma, for example by pretending their medications were for unrelated conditions. Completers were more comfortable communicating with health care workers than were defaulters. Efforts to facilitate successful IPT completion must include appropriate counseling and education for individual patients and addressing inefficiencies within the health care system in order to minimize patients' financial and logistical burden. These patient-level and structural changes are necessary for IPT to successfully reduce TB incidence in this resource-limited setting.

Antiretroviral therapy initiation and adherence in rural South Africa: community health workers' perspectives on barriers and facilitators.

South Africa has the largest global HIV/AIDS epidemic, but barriers along the HIV care continuum prevent patients from initiating and adhering to antiretroviral therapy (ART). To qualitatively explore reasons for poor ART initiation and adherence rates from the unique perspective of community health workers (CHWs), we conducted focus groups during May-August 2014 with 21 CHWs in rural Msinga, KwaZulu-Natal. Interviews were audio-recorded, transcribed, and translated from Zulu into English. Hybrid deductive and inductive analytical methods were applied to identify emergent themes. Multiple psychosocial, socioeconomic, and socio-medical barriers acted at the level of the individual, social network, broader community, and healthcare environment to simultaneously hinder initiation of and adherence to ART. Key themes included insufficient patient education and social support, patient dissatisfaction with healthcare services, socioeconomic factors, and tension between ART and alternative medicine. Fear of lifelong therapy thwarted initiation whereas substance abuse principally impeded adherence. In conclusion, HIV/AIDS management requires patient counselling and support extending beyond initial diagnosis. Treating HIV/AIDS as a chronic rather than acute infectious disease is key to improving ART initiation and long-term adherence. Public health strategies include expanding CHWs' roles to strengthen healthcare services, provide longitudinal patient support, and foster collaboration with alternative medicine providers.

Diagnostics for pulmonary tuberculosis.

Tuberculosis (TB) remains a leading cause of human suffering and mortality despite decades of effective treatment being available. Accurate and timely diagnosis remains an unmet goal. The HIV epidemic has also led to new challenges in the diagnosis of TB. Several new developments in TB diagnostics have the potential to positively influence the global campaign against TB. We aim to review the performance of both established as well as new diagnostics for pulmonary TB in adults, and discuss the ongoing challenges.

Considerations when prescribing opioid agonist therapies for people living with HIV.

INTRODUCTION: Medications for opioid use disorder (MOUD) include opioid agonist therapies (OAT) (buprenorphine and methadone), and opioid antagonists (extended-release naltrexone). All forms of MOUD improve opioid use disorder (OUD) and HIV outcomes. However, the integration of services for HIV and OUD remains inadequate. Persistent barriers to accessing MOUD underscore the immediate necessity of addressing pharmacoequity in the treatment of OUD in persons with HIV (PWH). AREAS COVERED: In this review article, we specifically focus on OAT among PWH, as it is the most commonly utilized form of MOUD. Specifically, we delineate the intersection of HIV and OUD services, emphasizing their integration into the United States Ending the HIV Epidemic (EHE) plan by offering comprehensive screening, testing, and treatment for both HIV and OUD. We identify potential drug interactions of OAT with antiretroviral therapy (ART), address disparities in OAT access, and present the practical benefits of long-acting formulations of buprenorphine, ART, and pre-exposure prophylaxis for improving HIV prevention and treatment and OUD management. EXPERT OPINION: Optimizing OUD outcomes in PWH necessitates careful attention to diagnosing OUD, initiating OUD treatment, and ensuring medication retention. Innovative approaches to healthcare delivery, such as mobile pharmacies, can integrate both OUD and HIV and reach underserved populations.

HIV and Substance Use Disorders.

Over 1.2 million Americans aged 13 years and older have been diagnosed with human immunodeficiency virus (HIV). While HIV incidence has been declining since 2017, the risk of HIV acquisition and transmission persists among persons who use drugs via injection drug use and unprotected sexual intercourse associated with substance use. Untreated substance use disorder (SUD) is associated with poor adherence to HIV antiretroviral therapy, poor HIV outcomes, and increased risk for HIV acquisition. Herein, we describe the intertwined syndemic of HIV and SUD, as well as treatment strategies and evidence-based public health efforts to engage and retain persons who use drugs into care.

Higher methadone dose at time of release from prison predicts linkage to maintenance treatment for people with HIV and opioid use disorder transitioning to the community in Malaysia.

BACKGROUND: Incarcerated people with HIV and opioid-dependence often experience poor post-release outcomes in the absence of methadone maintenance treatment (MMT). In a prospective trial, we assessed the impact of methadone dose achieved within prison on linkage to MMT after release. METHODS: From 2010 to 2014, men with HIV (N = 212) and opioid dependence before incarceration were enrolled in MMT within 6 months of release from Malaysia's largest prison and followed for 12-months post-release. As a prospective trial, allocation to MMT was at random and later by preference design (predictive nonetheless). MMT dosing was individually targeted to minimally achieve 80 mg/day. Time-to-event analyses were conducted to model linkage to MMT after release. FINDINGS: Of the 212 participants allocated to MMT, 98 (46 %) were prescribed higher dosages (≥80 mg/day) before release. Linkage to MMT after release occurred in 77 (36 %) participants and significantly higher for those prescribed higher dosages (46% vs 28 %; p = 0.011). Factors associated with higher MMT dosages were being married, on antiretroviral therapy, longer incarceration periods, having higher levels of depression, and methadone preference compared to randomization. After controlling for other variables, being prescribed higher methadone dosage (aHR: 2.53, 95 %CI: 1.42-4.49) was the only independent predictor of linkage to methadone after release. INTERPRETATION: Higher doses of methadone prescribed before release increased the likelihood of linkage to MMT after release. Methadone dosing should be introduced into international guidelines for treatment of opioid use disorder in prisons and further post-release benefits should be explored. FUNDING: National Institute of Drug Abuse (NIDA).

Efficacy and Impact of Peer-Led Education for Persons with Tuberculosis in Kampala, Uganda: A Pre-Post Implementation Study.

Introduction: Universal TB education and counseling (TEC) is routinely recommended for promoting knowledge and medication adherence, but the quality of delivery often varies because of inadequate clinic space, time, and health worker training. Peer-led counseling is a promising but understudied solution to these challenges. We sought to evaluate the efficacy of a peer-led TEC strategy among newly diagnosed adults initiating TB treatment in Kampala, Uganda. Methods: We conducted a longitudinal, pre-post implementation study comparing the routine, healthcare-worker-led and peer-led strategies for delivery of TEC to consecutive adult persons with TB at a large, public primary-care clinic. Trained staff administered a standardized TB knowledge survey to all persons with TB immediately following TEC. We compared TB knowledge by type of TEC received using t-tests. Results: We enrolled 161 persons with TB, 80 who received conventional TEC from health workers between June and July 2018, and 81 who received peer-led TEC between August and November 2019. The proportions of women (28% vs. 31%, p = 0.64) and persons living with HIV (36% vs 30%, p = 0.37) were similar in the pre- and post-implementation periods. Peer-led TEC was associated with a more significant increase in disease-specific (difference +21%, 95% CI +18% to + 24%, p < 0.0001) and treatment-specific TB knowledge scores (difference +14%, 95% CI + 10% to + 18%, p< 0.0001) than routine healthcare worker-delivered TEC. All TB knowledge constructs were significantly higher for those in the post-implementation period than those in the pre-implementation period. Nine participants met our threshold for adequate knowledge (score ≥ 90%) for disease-specific TB knowledge in the pre-implementation period compared to 63 (78%) in the post-implementation period (+67%, 95% CI + 55% - +78%, p < 0.001). Twenty-eight (35%) met the adequate knowledge threshold for TB treatment-specific knowledge in the pre-implementation period compared to 60 (74%) in the post-implementation period (+ 39%, 95% CI + 25 to + 53%, p < 0.0001). Finally, the proportion achieving TB treatment success (cure or completed) increased substantially from the pre-implementation period (n = 49, 68%) to the post-implementation period (n = 63, 88%), a difference of + 19% (95% CI + 6% to + 33%, p = 0.005). Conclusion: Our findings suggest that peer-led TEC is more efficacious than routine TEC at improving TB knowledge and treatment outcomes. Future studies should evaluate the implementation and effectiveness of the peer-led TEC strategy when scaled to a larger number of clinics.