Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIV.

BACKGROUND: Despite renewed focus on molecular tuberculosis (TB) diagnostics and new antimycobacterial agents, treatment outcomes for patients co-infected with drug-resistant TB and human immunodeficiency virus (HIV) remain dismal, in part due to lack of focus on medication adherence as part of a patient-centered continuum of care. OBJECTIVE: To review current barriers to drug-resistant TB-HIV treatment and propose an alternative model to conventional approaches to treatment support. DISCUSSION: Current national TB control programs rely heavily on directly observed therapy (DOT) as the centerpiece of treatment delivery and adherence support. Medication adherence and care for drug-resistant TB-HIV could be improved by fully implementing team-based patient-centered care, empowering patients through counseling and support, maintaining a rights-based approach while acknowledging the responsibility of health care systems in providing comprehensive care, and prioritizing critical research gaps. CONCLUSION: It is time to re-invent our understanding of adherence in drug-resistant TB and HIV by focusing attention on the complex clinical, behavioral, social, and structural needs of affected patients and communities.

Barriers to prenatal care: factors associated with late initiation of care in a middle-class midwestern community.

BACKGROUND: Barriers to prenatal care have been extensively investigated in low-income and inner-city communities. Less attention has been directed to the study of prenatal care among middle- and upper-class pregnant women. This study describes perceived barriers and factors associated with late initiation of prenatal care in a predominantly middle- to upper-class midwestern community. METHODS: Consenting women in Olmsted County, Minnesota, who were attending a clinic for their first obstetric visit completed a self-administered questionnaire that queried the presence of factors making it difficult to receive prenatal care, perception about the importance of prenatal care, expectations at the first prenatal care visit, and sociodemographic factors. RESULTS: Of the 813 women aged 14 to 47 years, 692 (86%) had their first prenatal visit within the first trimester of pregnancy. Only 98 (12%) women reported external barriers to receiving prenatal care. These factors included difficulty in getting an appointment (46.9%), problems finding child care (26.5%), and lack of transportation (14.3%). In multivariable logistic regression analyses, late initiation of care was associated with patient perception of prenatal care as being less than very important (odds ratio [OR] = 4.1, 95% confidence interval [CI], 1.7-9.7); external barriers to prenatal care (OR = 2.9, 95% CI, 1.6-5.4); annual income < $17,000 (OR = 2.9, 95% CI, 1.5-5.7); and an unintended pregnancy (OR = 2.1, 95% CI, 1.3-3.5). Multiparous women and women older than 35 years were more likely to perceive prenatal care as less than very important (OR = 3.9, 95% CI, 2.5-14.6 and OR = 2.9, 95% CI, 1.2-6.8, respectively). CONCLUSIONS: These findings suggest that perceptions about the importance of prenatal care may play a greater role in the initiation of care among this group of women than is recognized. Women with more experience with pregnancy appear to place slightly less importance on prenatal care.