LIMITATIONS •
•
•
Personality disorders are under diagnosed in this study according to the project psychiatrist, and based on reports in patients’ files where personality disorders are only ‘queried’. Treatment for this problem is not possible within the programme, and more information on a patient’s history would be needed to make this diagnosis. Patients are either treated as part of the MSF cohort or the Global Fund (GF) cohort. Both cohorts receive the psycho-social intervention, but only patients in the MSF cohort have their TB treatment within the programme. This means for patients treated for TB that is paid for under Global Fund (33 or 56%) - some baseline medical characteristics are not available in the data base. This includes variables such as whether the patient experiences adverse events from treatment, whether the patient smokes, the x-ray cavity profile. Patients responses on the PHQ9, GAD7, AUDIT and ASSIST questionnaires may not always accurately represent the patients actual state of mental health, and in some cases patients were included into the cohort despite normal scores,
•
as it was suspected by a psychiatrist, social worker, nurse, doctor or counsellor-educator that the patient was struggling with alcohol. Honesty in these forms might increase as time in the programme increases, as the counsellor-educators and other health care workers’ relationship with the patient improves. This may partially explain why some scores go up over the course of the programme, but it may also be because patients leave the IPD at around 4- 6 months so have more access to alcohol after their baseline assessment, which is done in IPD. Half (3) of all women offered the opportunity to take part in the indepth interviews refused to take part in an interview, whereas only 1 man refused to take part in interviews. This is thought to be because the subject matter of the interview, and especially drinking, is more stigmatised for women. Furthermore, the women who did agree to participate, did not talk openly about harmful or high levels of alcohol use, and in general seemed to give formal and socially acceptable answers, in comparison to the information available
•
through the patient’s files. A small number of the men also seemed to share a more formal and socially acceptable description of their current lives than would be indicated by the information in their files. It was not possible to do in-depth interview patients who were voluntarily LTFU from the programme, or with patients who are recorded as having an alcohol and other substance abuse disorder, so, there is some response bias present in interviews as patients who were not adherent to the programme were under-represented. Though we were able to speak to 7 patients with high risk of adherence issues, and 3 who had adherence below 90%, also with one patient who was taken off treatment around the time of interview due to very poor adherence, and recorded at LTFU. Counsellors recommended against inviting the two patients with alcohol and other drug problems who were eligible for interview due to the risk they would not accept, and one is now LTFU. We did try to invite another patient voluntarily LTFU, with whom it was thought it might be possible he would agree to interview, but he could not be contacted.
DISCUSSION OVERALL ADHERENCE TO TB TREATMENT Adherence to MDR/RR-TB treatment for patients enrolled in the person-centred multidisciplinary psychosocial support and harm reduction intervention is high at 95%. This initial result, whilst not yet final, is encouraging, given the complex issues faced by the patients included in the programme, and given forced hospitalisation was not required for the majority (~only
32
around 12%) to achieve this favourable result. Thus far, this study showed that there is little variation in adherence in most patient sub groups - which may be an early indication that the person-centred approach is really tailored to all individuals, though this it may simply be to low power, so would need confirmation when more data is available. There was however some indication that patients who are in union, who have current abuse of substances other than
alcohol, who have hepatitis B or C and who have not previously been on TB treatment, and those that are employed might have more challenges with adherence than other patients. Whilst it was not possible to formally compare the adherence in this cohort, we have collected information on adherence for other MDR/RR TB patients in Minsk. Median overall adherence for the 59 patients with a disorder due to the use of alcohol in the study
