Delays in TB treatment among people with pulmonary TB in East Africa: findings from a prospective cohort study

Abstract Background Although timely tuberculosis (TB) diagnosis and treatment are essential to TB elimination, care delays remain a challenge. Understanding factors associated with delayed TB diagnosis and treatment may inform interventions. Methods The TB Sentinel Research Network of the International epidemiology Databases to Evaluate AIDS is a prospective study of people aged ≥15 with pulmonary TB. At sites in Eldoret, Kenya, and Mbarara, Uganda, questionnaires ascertained timing of recalled TB symptom onset; number/setting of healthcare visits prior to TB diagnosis; symptoms; demographics; food insecurity; and TB- and HIV-related stigma. Robust negative binomial regression was used to examine factors associated with longer overall duration from TB symptom onset to documented treatment initiation. Results Among 264 participants—median age 33 years (IQR 25-43), 67% male, 31% people living with HIV (PLHIV), 51% urban residents—median duration from TB symptom onset to treatment initiation was 65.5 days (IQR 33-131). Longer time to TB treatment was associated with female sex, adjusted incidence rate ratio (aIRR) 1.27, 95% CI (1.00-1.61); previous care-seeking at a pharmacy, aIRR 1.53 (1.22-1.92); and dyspnea, aIRR 1.43 (1.09-1.86), or fatigue, 1.63 (1.11-2.37) at initiation. Shorter duration to TB treatment was associated with HIV-positive status, aIRR 0.50 (0.39-0.64). Among PLHIV, shorter duration to TB treatment was associated with CD4 cell count <200 cells/mm3, aIRR 0.63 (0.43-0.93). Conclusions Interventions are needed to increase community-level TB diagnostic access, including at pharmacies and lower levels of care. Decentralized TB testing strategies and tailored interventions for groups with lower care access should be pursued.