Pathways to care and preferences for improving tuberculosis services among tuberculosis patients in Zambia

Background: Delays in the diagnosis of tuberculosis (TB) contribute to a substantial proportion of TB-related mortality, especially among people living with HIV (PLHIV). We sought to characterize the diagnostic journey for HIV-positive and HIV-negative patients with a new TB diagnosis in Zambia, to understand drivers of delay, and characterize their preferences for service characteristics to inform improvements in TB services. Methods: We assessed consecutive adults with newly microbiologically-confirmed TB at two public health treatment facilities in Lusaka, Zambia. We administered a survey to document critical intervals in the TB care pathway (time to initial care-seeking, diagnosis and treatment initiation), identify bottlenecks and their reasons. We quantified patient preferences for a range of characteristics of health services using a discrete choice experiment (DCE) that assessed 7 attributes (distance, wait times, hours of operation, confidentiality, sex of provider, testing incentive, TB test speed and notification method). Results: Among 401 patients enrolled (median age of 34 years, 68.7% male, 46.6% HIV-positive), 60.9% and 39.1% were from a first-level and tertiary hospital, respectively. The median time from symptom onset to receipt of TB treatment was 5.0 weeks (IQR: 3.6-8.0) and was longer among HIV-positive patients seeking care at a tertiary hospital than HIV-negative patients (6.4 vs. 4.9 weeks, p=0.002). The time from symptom onset to initial presentation for evaluation accounted for the majority of time until treatment initiation (median 3.0 weeks, IQR: 1.0-5.0) – an important minority of 11.0% of patients delayed care-seeking >=8 weeks. The DCE found that patients strongly preferred same-day TB test results (relative importance, 37.2%), facilities close to home (18.0%), and facilities with short wait times (16.9%). Patients were willing to travel to a facility up to 7.6 kilometers further away in order to access same-day TB test results. Preferences for improving current TB services did not differ according to HIV-status. Conclusions: Prolonged intervals from TB symptom onset to treatment initiation were common, especially among PLHIV, and were driven by delayed health-seeking. Addressing known barriers to timely diagnosis and incorporating patients’ preferences into TB services, including same-day TB test results, may facilitate earlier TB care engagement in high burden settings.研究背景：结核病（Tuberculosis, TB）诊断延迟在结核病相关死亡中占比颇高，尤其在艾滋病毒感染者（People Living with HIV, PLHIV）群体中更为显著。本研究旨在刻画赞比亚新发结核病确诊患者（分为艾滋病毒阳性与阴性群体）的诊断历程，明确诊断延迟的驱动因素，并梳理患者对医疗服务特征的偏好，以期为结核病医疗服务的优化提供参考。 研究方法：本研究纳入赞比亚卢萨卡两家公立医疗服务机构中经微生物学确诊的新发结核病成年连续病例。通过问卷调查记录结核病诊疗路径中的关键时间间隔（首次就医时间、确诊时间与启动治疗时间），识别诊疗瓶颈及其成因。本研究采用离散选择实验（Discrete Choice Experiment, DCE）量化患者对医疗服务多项特征的偏好，实验涵盖7项属性：就医距离、等候时长、门诊时长、隐私保护、接诊医师性别、检测补贴、结核病检测速度以及通知方式。 研究结果：本研究共纳入401例确诊患者，中位年龄为34岁，其中男性占比68.7%，艾滋病毒感染者占比46.6%；60.9%的患者来自一级医院，39.1%来自三级医院。从症状出现到启动结核病治疗的中位时间为5.0周（四分位距（Interquartile Range, IQR）：3.6~8.0），其中在三级医院就诊的艾滋病毒阳性患者的该时间长于艾滋病毒阴性患者（6.4周 vs 4.9周，p=0.002）。从症状出现到首次就诊接受评估的时间占启动治疗前总时长的大部分（中位时间3.0周，四分位距（Interquartile Range, IQR）：1.0~5.0），另有11.0%的患者就医延迟时长≥8周。离散选择实验结果显示，患者最为偏好当日出具结核病检测结果（相对重要性占比37.2%）、离家近的医疗机构（18.0%）以及等候时长较短的医疗机构（16.9%）。患者愿意为获取当日结核病检测结果多前往最远7.6公里外的医疗机构。不同艾滋病毒感染状态的患者对当前结核病医疗服务优化的偏好并无差异。 研究结论：结核病症状出现至启动治疗的间隔时长过长的情况十分普遍，尤其在艾滋病毒感染者（People Living with HIV, PLHIV）群体中，而这一现象主要由就医延迟所致。针对性解决及时诊断的已知障碍，并将患者偏好纳入结核病医疗服务体系（例如提供当日检测结果），或可在结核病高负担地区推动患者更早接受结核病诊疗服务。