Understanding Nonadherence to Tuberculosis Medications in India Using Urine Drug Metabolite Testing: A Cohort Study. (5th May 2021)

• Record Type: Journal Article
• Authors: Subbaraman, Ramnath; Thomas, Beena E; Kumar, J Vignesh; Thiruvengadam, Kannan; Khandewale, Amit; Kokila, S; Lubeck-Schricker, Maya; Ranjith Kumar, M; Gaurkhede, Gunjan Rahul; Walgude, Apurva Shashikant; Hephzibah Mercy, J; Kumbhar, Jagannath Dattatraya; Eliasziw, Misha; Mayer, Kenneth H; Haberer, Jessica E
• Is Part Of: Open forum infectious diseases. Volume 8:Number 6(2021)
• Publication Date: 2021-05-05
• Subjects: adherence -- alcohol use -- HIV -- India -- tuberculosis; Communicable diseases -- Periodicals; Medical microbiology -- Periodicals; Infection -- Periodicals; 616.9
• DOI: 10.1093/ofid/ofab190
• Languages: English
• ISSNs: 2328-8957

Abstract

Abstract: Background: Poor adherence to tuberculosis (TB) treatment is associated with disease recurrence and death. Little research has been conducted in India to understand TB medication nonadherence. Methods: We enrolled adult drug-susceptible TB patients, approximately half of whom were people with human immunodeficiency virus (PWH), in Chennai, Vellore, and Mumbai. We conducted a single unannounced home visit to administer a survey assessing reasons for nonadherence and collect a urine sample that was tested for isoniazid content. We described patient-reported reasons for nonadherence and identified factors associated with nonadherence (ie, negative urine test) using multivariable logistic regression. We also assessed the association between nonadherence and treatment outcomes. Results: Of 650 participants in the cohort, 77 (11.8%) had a negative urine test. Nonadherence was independently associated with daily wage labor (adjusted odds ratio [aOR], 2.7; confidence interval [CI], 1.1–6.5; P = .03), the late continuation treatment phase (aOR, 2.0; CI, 1.1–3.9; P = .03), smear-positive pulmonary disease (aOR, 2.1; CI, 1.1–3.9; P = .03), alcohol use (aOR, 2.5; CI, 1.2–5.2; P = .01), and spending ≥30 minutes collecting medication refills (aOR, 6.6; CI, 1.5–29.5; P = .01). People with HIV reported greater barriers to collecting medications than non-PWH. Among 167 patients reporting missing doses, reported reasons included traveling from home, forgetting, feeling depressed, and running out of pills. The odds of unfavorable treatment outcomes were 4.0 (CI, 2.1–7.6) times higher among patients with nonadherence ( P < .0001). Conclusion: Addressing structural and psychosocial barriers will be critical to improve TB treatment adherence in India. Urine isoniazid testing may help identify nonadherent patients to facilitate early intervention during treatment. Abstract : We evaluated adherence to tuberculosis medications in 650 Indian patients by conducting urine isoniazid tests collected during unannounced home visits. Structural barriers to collecting medication refills and psychosocial barriers emerged as the most important factors contributing to medication nonadherence.