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.