Evaluation of determinants, acceptability and effectiveness of community-based management of multidrug-resistant tuberculosis (MDR-TB) in Nigeria

Background: Growing multidrug-resistant tuberculosis (MDR-TB) worldwide and new effective and affordable treatment modalities required exploration of options such as the community model of MDR-TB treatment (CM), as introduced in Nigeria. This study explores its acceptability implementation and follow-up for infection control, programme characteristics influencing the model outcomes, economic impact, and cost-effectiveness. The study also evaluates the Nigerian experience of the End TB Strategy target of impoverishment due to MDR-TB.

Methods: Mixed methods were employed. Qualitative data were obtained from semi-structured interviews with 21 MDR-TB patients in Nigeria. An iterative interview process with adapted topic guides led to data saturation, and themes emerged inductively from thematic analysis. Effectiveness and cost-effectiveness analysis compares community (CM) and hospital-based MDR-TB care (HM). We assessed treatment outcomes data from the medical records of 423 MDR-TB patients to evaluate the effectiveness of HM and CM based on WHO treatment criteria. Treatment success” is defined as the sum of cure and treatment completion. “Cure” is the “treatment completion” with at least three negative cultures taken at least 30 days apart after the intensive phase in the absence of “treatment failure. Costs were assessed from a societal perspective and included health system costs and a cross-sectional survey of MDR-TB patients at different stages of treatment to obtain direct and indirect costs. Cost-effectiveness was calculated as the cost per patient successfully treated and incremental cost-effectiveness ratio (ICER) per patient cured or successful treatment. We also assessed the expected costs and health effects of HM vs CM using a decision-analytic model from the perspective of the Nigerian national healthcare system.

Findings: Emergent themes indicate strong patient preference and acceptability of CM; mixed feelings about the risk and points of MDR-TB transmission; stigma influencing infection control and community support worker attitudes influencing the expansion of resistance. The median monthly cost incurred by patients was higher in HM than in CM, with US $55.38 (IQR: 27.90–65.69) versus US $28.72 (IQR: 13.68–38.40) (p < 0.001) for HM and CM, respectively, representing 135% and 70% of their mean monthly incomes. The total treatment cost for a Nigerian patient treated successfully for MDR-TB was estimated at US $13,459 for HM and $8,587 for CM with the same level of clinical effectiveness (treatment success of 65.5% and 68.0%, respectively; p = 0.608). Thus, CM improved cost-effectiveness by 36%. The average cost-effectiveness ratio (CER) per patient treated successfully at HM was US $135 and US $86 per patient treated successfully at CM. The incremental cost-effectiveness ratio (ICER) of MDR-TB treatment at CM was US $ -1190 per patient cured or treated successfully. When we assumed smear-positive and negative MDR-TB patients separately, CM was consistently more cost-effective at an average CER of US $110 per patient cured or treated successfully at CM and US $175 per patient cured or treated successfully at HM (smear-negative MDR-TB). For smear-positive MDR-TB, the average CER per patient cured or treated successfully was US $127 and US $203 at CM and HM, respectively. On multivariate analysis, adjusting for age, HIV, sex, patient type, TB treatment history, resistance pattern, model of care and regimens, there was no change in treatment outcomes if patients were treated at the CM vs HM (adjusted odds ratio [aOR] 0.92; 95% CI 0.59 – 1.46, p = 0.735).

Conclusion: Community-based-MDR-TB was seen as the patients' most preferred and acceptable model because of its convenience, which enhanced recovery, enabled social interaction, and promoted mental health. It also allowed economic productivity and earning potential. It improved the health system, patient affordability, and cost-effectiveness at ICER of US $-1190. However, CM was challenged by ineffective supervision and the need for more commitment among patients and community support workers to reducing community transmission. Despite social protection, patients experienced further impoverishment. The level of impoverishment experienced by MDR-TB patients in Nigeria suggests that it requires appropriate innovative patient-centred social protection for the Nigerian TB control programme to achieve the End TB Strategy targets and UHC. The findings also point to a need for continuous patient counselling and education to reduce stigma and improve coordination between patients and support workers to help patients comply with guidelines and impact the treatment outcome.