Browsing by Author "Loveday, Marian Patricia."

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Association between health systems performance and treatment outcomes in patients co-infected with MDR-TB and HIV in KwaZulu-Natal, South Africa: implications for TB programmes.
(Public Library of Science., 2014) Loveday, Marian Patricia.; Padayatchi, Nesri.; Wallengren, Kristina.; Roberts, Jacquelin.; Brust, James C. M.; Ngozo, Jacqueline.; Master, Iqbal.; Voce, Anna Silvia.
Objective: To improve the treatment of MDR-TB and HIV co-infected patients, we investigated the relationship between health system performance and patient treatment outcomes at 4 decentralised MDR-TB sites. Methods: In this mixed methods case study which included prospective comparative data, we measured health system performance using a framework of domains comprising key health service components. Using Pearson Product Moment Correlation coefficients we quantified the direction and magnitude of the association between health system performance and MDR-TB treatment outcomes. Qualitative data from participant observation and interviews analysed using systematic text condensation (STC) complemented our quantitative findings. Findings: We found significant differences in treatment outcomes across the sites with successful outcomes varying from 72% at Site 1 to 52% at Site 4 (p<0.01). Health systems performance scores also varied considerably across the sites. Our findings suggest there is a correlation between treatment outcomes and overall health system performance which is significant (r = 0.99, p<0.01), with Site 1 having the highest number of successful treatment outcomes and the highest health system performance. Although the 'integration' domain, which measured integration of MDR-TB services into existing services appeared to have the strongest association with successful treatment outcomes (r = 0.99, p<0.01), qualitative data indicated that the 'context' domain influenced the other domains. Conclusion: We suggest that there is an association between treatment outcomes and health system performance. The chance of treatment success is greater if decentralised MDR-TB services are integrated into existing services. To optimise successful treatment outcomes, regular monitoring and support are needed at a district, facility and individual level to ensure the local context is supportive of new programmes and implementation is according to guidelines.
The association of organizational contextual factors and HIV-Tuberculosis service integration following exposure to quality improvement interventions in primary healthcare clinics in rural KwaZulu-Natal.
(2021) Gengiah, Santhanalakshmi.; Loveday, Marian Patricia.; Taylor, Myra.
A key strategy to reduce Tuberculosis (TB)-related mortality among people living with HIV is integrating HIV and TB diagnostic and treatment services. In South Africa, integrated HIV-TB service provision is standard of care, however, there is evidence that patients accessing primary healthcare clinics (PHC) are missed for HIV and TB testing and screening, diagnosis, linkage to treatment, and preventive services. Gaps in the HIV-TB care cascade are indicative of weaknesses in healthcare systems at the frontline. Quality Improvement (QI) collaboratives are a widely adopted approach to facilitating improvement among multiple clinics and scaling up best practices to improve on a given health topic. Little is known of the effectiveness of QI collaboratives and less is known of the role of organizational contextual factors (OCFs) in influencing the success of QI collaboratives to improve integrated HIV-TB services. Scaling up TB/HIV Integration (SUTHI) was a cluster-randomised trial designed to test the effectiveness of a QI intervention to enhance integrated HIV-TB services on mortality in HIV, TB, and HIV-TB patients. The study was from 01 December 2016-31 December 2018. Sixteen nurse supervisors (clusters) overseeing 40 PHC clinics were randomized (1:1) to receive either a structured QI intervention (QI group), which comprised, clinical training, three QI workshops timed at 6-month intervals, and in-person mentorship visits; or standard of care (SOC group) supervision and support for HIV-TB service delivery. This PhD project was a nested sub-study embedded in the SUTHI trial which aimed to describe and assess the influence of OCFs on the QI intervention to improve process indicators of HIV-TB services. A description of the QI intervention, including change ideas generated and lessons learned from practical application of the intervention in 20 QI clinics are presented in Paper I. Baseline performance of indicators was highlighted as important in influencing the size of improvements. OCFs that undermined the QI process were poor data quality, data capturing backlogs, lack of data analytic skills among clinic staff, poor transfer of training knowledge to peers, low clinic staff motivation to consistently track performance and limited involvement of the clinic management team in QI activities due to heavy workloads. A comparison between the QI and SOC group clinics showed that the QI intervention was only effective in improving two of five HIV-TB indicators, HIV testing services (HTS) andIsoniazid Preventive Therapy (IPT) initiation rates in new antiretroviral therapy patients. HTS was 19% higher (94.5% versus (vs) 79.6%; Relative Risk (RR)=1.19; 95% CI:1.02% - 1.38%; p=0.029) and IPT initiation was 66% higher (61.2% vs 36.8%; RR=1.66; 95% CI:1.02% -2.72%; p=0.044), in the QI group compared to the SOC group. Small clusters showed larger improvements in IPT initiation rates compared to big clusters, likely due to better coordination of efforts (Paper II). Several OCFs were quantitatively assessed and inserted into a linear mixed model to determine which factors likely influenced the improvement observed in the IPT initiation rates (Paper III). The practice of monitoring data for improvement was significantly associated with higher IPT initiation rates (Beta coefficient (β)=0.004; p=0.004). The main recommendations made from the PhD project are to encourage the practice of monitoring data for improvement among clinic teams; provision of widespread QI training for all levels of staff, different staff categories and leadership; to ensure good quality of routine data, and provision of regular performance feedback from upper management to the clinics.
Community-based care vs. centralised hospitalisation for MDR-TB patients, KwaZulu-Natal, South Africa.
(International Union Against Tuberculosis and Lung Disease., 2015) Loveday, Marian Patricia.; Wallengren, Kristina.; Brust, James C. M.; Roberts, Jacquelin.; Voce, Anna Silvia.; Margot, Bruce.; Ngozo, Jacqueline.; Master, Iqbal.; Cassell, Gail H.; Padayatchi, Nesri.
Abstract available in pdf.
Comparing early treatment outcomes of MDR-TB in a decentralised setting with a centralised setting in KwaZulu-Natal, South Africa.
(International Union against Tuberculosis and Lung Disease., 2012) Loveday, Marian Patricia.; Wallengren, Kristina.; Voce, Anna Silvia.; Margot, Bruce.; Reddy, T.; Master, Iqbal.; Brust, James C. M.; Chaiyachati, K.; Padayatchi, Nesri.
Setting—In KwaZulu-Natal, South Africa, a TB and HIV endemic setting, prolonged hospitalisation for the treatment of the growing number of MDR-TB patients is not possible or effective. Objective—We compared early treatment outcomes in patients with MDR-TB, with and without HIV co infection, at a central, urban, referral hospital with four decentralised rural sites. Design—This is an operational, prospective cohort study of patients between 1 July 2008 to 30 November 2009, where culture conversion, time-to-culture-conversion, survival and predictors of these outcomes were analysed. Results—Of the 860 patients with MDR-TB, 419 were at the decentralised sites and 441 at the central hospital. Overall, 71% were HIV co-infected.
Drug-resistant tuberculosis control in South Africa: scientific advances and health system strengthening are complementary.
(Informa., 2014) Padayatchi, Nesri.; Loveday, Marian Patricia.; Naidu, Naressa.
Abstract available in pdf.
The impact of the introduction of direct first and second-line reflex testing in the management of drug-resistant Tuberculosis at Greytown Hospital, Umzinyathi District, KwaZulu-Natal.
(2020) Sneyd, Tamara.; Mlisana, Koleka Patience.; Loveday, Marian Patricia.
Background Drug resistant tuberculosis (DR-TB) is a serious public health issue both globally and nationally, with South Africa and Kwazulu-Natal, in particular, being among the regions with the highest burden of DR-TB. Detecting drug resistance and initiating patients onto the appropriate therapy, in the shortest possible time, is of utmost importance to the effective management of DR-TB. The development of molecular diagnostic techniques allows for more rapid diagnosis of TB, as well as drug resistance, leading to earlier diagnosis and subsequent initiation onto appropriate treatment. For phenotypic drug susceptibility testing (DST), the laboratory turnaround time is 4 – 6 weeks, thus patients are either initiated onto empiric and sometimes inappropriate treatment or have to wait to be initiated onto appropriate therapy, remaining untreated and infectious for extended periods of time. The introduction of GeneXpert testing revolutionised TB diagnostics as it allowed for diagnosis of TB whilst also providing susceptibility results for rifampicin within a few hours. Direct 1st and 2nd line LPA testing was included in the DR-TB management algorithm to further reduce the time to treatment initiation of multidrug resistant TB (MDR-TB) and extensively drug resistant TB (XDR-TB). This also ostensibly reduces the amount of time a patient is transmissible for and improves treatment outcomes. This study was undertaken to assess the impact of the introduction of the direct 1st and 2nd LPA reflex testing on the management of DR-TB in the Umzinyathi District of Kwazulu-Natal. Methods The cohorts before and after the roll-out of direct 1st and 2nd line LPA testing were analysed for patient characteristics, diagnostic information, time to appropriate treatment initiation and treatment outcomes. Furthermore, the diagnostic tests were compared to ascertain if 1st and 2nd line LPA is comparable to phenotypic DST for drug susceptibility testing. Results There were 141 patients included in the 2015/2016 cohort before direct 1st and 2nd LPA was included in the algorithm, and 102 patients in the 2017/2018 cohort after its implementation. There was a significant decrease between cohort 1 and cohort 2, in the laboratory turnaround time for both 1st line LPA, which decreased from 36 days (IQR 23 – 60) to 17 days (IQR 11 – 30), respectively, and 2nd line LPA, which compared to phenotypic DST, decreased from 45 (IQR 23 – 67) to 21 days (IQR 12 – 50). Time to appropriate treatment initiation was similar across both cohorts for RR- and MDR-TB, from 8 days (IQR 5 – 13) to 9 days (IQR 7 – 29) in the second for RR-TB, and from 8 days in cohort 1 (IQR 6 – 20) to 12 days (IQR 6 – 50) in cohort 2 for MTB-TB. The time to appropriate treatment was significantly reduced in XDR-TB patients from 267 (IQR 145 – 796) to 62 days (IQR 45 – 182) v (p=0.018). Moreover, the treatment outcomes in XDR-TB improved after the roll-out of direct 1st and 2nd line LPA. Xpert, 1st line and 2nd line LPA performed well compared to phenotypic DST for antibiotic resistance detection. Conclusion The laboratory turnaround time and time to appropriate treatment initiation improved after the implementation of direct 1st and 2nd line LPA. Despite a delay in initiating therapy after laboratory diagnosis, there were positive impacts found regarding treatment outcomes of XDR-TB. Patients were initiated on the appropriate treatment, in response to 2nd line LPA results, in the first instance, which improved treatment success rates in XDR-TB patients. Keywords: Mycobacterium tuberculosis, line probe assay, MDR-TB, XDR-TB, phenotypic DST
MDR-TB patients in KwaZulu-Natal, South Africa: cost-effectiveness of 5 models of care.
(Public Library of Science., 2018) Loveday, Marian Patricia.; Wallengren, Kristina.; Reddy, Tarylee.; Besada, Donela.; Brust, James C. M.; Voce, Anna Silvia.; Desai, Harsha.; Ngozo, Jacqueline.; Radebe, Zanele.; Master, Iqbal.; Padayatchi, Nesri.; Daviaud, Emmanuelle.
Abstract available in pdf.