Community-supported self-administered tuberculosis treatment combined with active tuberculosis screening: a pilot experience in Conakry, Guinea

ABSTRACT

Directly observed treatment (DOT) for tuberculosis (TB) is recommended by the World Health Organization. However, DOT does not always meet patients’ preferences, burdens health facilities, and is hard to implement in settings where access to healthcare services is regularly interrupted. A model addressing these limitations of DOT is community-supported self-administered treatment (CS-SAT), in which patients who self-administer TB treatment receive regular visits from community members. Guinea is a country with a high TB burden, recurrent epidemics, and periodic socio-political unrest. We piloted a CS-SAT model for drug-susceptible TB patients in Conakry, led by community volunteers, who also conducted active TB case finding among household contacts and referrals for isoniazid preventive treatment (IPT) in children below 5 years old. We aimed to assess TB treatment outcomes of patients on CS-SAT and describe the number of patients identified with TB case finding and IPT provision. Prospectively enrolled bacteriologically confirmed TB patients, presenting to two facilities, received monthly TB medication. Community volunteers performed bi-weekly (initiation phase) and later monthly (continuation phase) home visits to verify treatment adherence, screen household contacts for TB, and assess IPT uptake in children under five. Among 359 enrolled TB patients, 237 (66.0%) were male, and 37 (10.3%) were HIV-positive. Three hundred forty (94.7%) participants had treatment success, seven (1.9%) died, seven (1.9%) experienced treatment failure, and five (1.4%) were lost-to-follow-up. Among 1585 household contacts screened for TB, 26 (1.6%) had TB symptoms, of whom five (19.2%) were diagnosed with pulmonary TB. IPT referral was done for 376 children from 198 households. In a challenging setting, where DOT is often not feasible, CS-SAT led to successful TB treatment outcomes and created an opportunity for active TB case finding and IPT referral. We recommend the Guinean CS-SAT model for implementation in similar settings.

KEYWORDS:

• SAT
• decentralized treatment
• TB-case finding
• TPT
• differentiated TB care

Responsible Editor Stig Wall

Responsible Editor Stig Wall

Acknowledgments

The authors would like to thank Damien foundation headquarters, which funded this study, colleagues at Damien Foundation Guinea, all health workers and mediators involved in this study, and all collaborators of the Guinean NTP. Finally, we would like to thank all supervisors and coaches who gave their time to accompany us in this project.

Author contributions

SHH and NOG conceived the idea. SHH, AD, GC, and LMD implemented the study. SHH and TG drafted the manuscript. TG analysed the data. TD, LR, and BJ supported the data interpretation and critically appraised the manuscript. All authors read and approved the final version of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics and consent

The Comité National d’Ethique pour la Recherche en Santé (CNERS) of Guinea National approved the study protocol (N°015/CNERS/18). Signed consent was obtained from all participants before starting the study. The study was performed in accordance with the ethical standards of the Declaration of Helsinki.

Paper context

Daily health facility-based DOT for TB is still standard of care in many countries in West and Central Africa, where access to health facilities is often limited for patients, yet flexibilities for decentralised TB treatment such as CS-SAT, which have shown positive outcomes elsewhere, are not yet widely implemented in the region. We present the outcomes of CS-SAT, in combination with household TB case finding in Guinea, contributing to the limited evidence from the region.

Data deposition

The data that support the findings of this study are openly available in figshare at https://doi.org/10.6084/m9.figshare.24211632.v1.

Additional information

Funding

This study was funded by Damien Foundation. Hassane-Harouna receives a PhD scholarship grant from the Institute of Tropical Medicine, funded by the Belgian Development Cooperation. The funders had no role in the design of the study, collection, analysis, and interpretation of data, and in the writing of the manuscript.