Wingfield Tom, Tovar Marco A, Huff Doug, Boccia Delia, Saunders Matthew J, Datta Sumona, Montoya Rosario, Ramos Eric, Lewis James J, Gilman Robert H, Evans Carlton
Clin Med (Lond). 2016 Dec;16(Suppl 6):s79-s91. doi: 10.7861/clinmedicine.16-6-s79.
Poverty drives tuberculosis (TB) rates but the approach to TB control has been disproportionately biomedical. In 2015, the World Health Organization's End TB Strategy explicitly identified the need to address the social determinants of TB through socio-economic interventions. However, evidence concerning poverty reduction and cost mitigation strategies is limited. The research described in this article, based on the 2016 Royal College of Physicians Linacre Lecture, aimed to address this knowledge gap. The research was divided into two phases: the first phase was an analysis of a cohort study identifying TB-related costs of TB-affected households and creating a clinically relevant threshold above which those costs became catastrophic; the second was the design, implementation and evaluation of a household randomised controlled evaluation of socio-economic support to improve access to preventive therapy, increase TB cure, and mitigate the effects of catastrophic costs. The first phase showed TB remains a disease of people living in poverty - 'free' TB care was unaffordable for impoverished TB-affected households and incurring catastrophic costs was associated with as many adverse TB treatment outcomes (including death, failure of treatment, lost to follow-up and TB recurrence) as multidrug resistant (MDR) TB. The second phase showed that, in TB-affected households receiving socio-economic support, household contacts were more likely to start and adhere to TB preventive therapy, TB patients were more likely to be cured and households were less likely to incur catastrophic costs. In impoverished Peruvian shantytowns, poverty remains inextricably linked with TB and incurring catastrophic costs predicted adverse TB treatment outcome. A novel socio-economic support intervention increased TB preventive therapy uptake, improved TB treatment success and reduced catastrophic costs. The impact of the intervention on TB control is currently being evaluated by the Community Randomized Evaluation of a Socio-economic Intervention to Prevent TB (CRESIPT) study.
贫困导致结核病发病率上升，但结核病控制方法在很大程度上一直是生物医学方面的。2015年，世界卫生组织的《终止结核病战略》明确指出，需要通过社会经济干预措施来解决结核病的社会决定因素。然而，关于减贫和成本缓解策略的证据有限。本文所述的研究基于2016年皇家内科医师学院林纳克讲座，旨在填补这一知识空白。该研究分为两个阶段：第一阶段是对一项队列研究进行分析，确定受结核病影响家庭与结核病相关的费用，并设定一个具有临床相关性的阈值，超过该阈值这些费用就会成为灾难性费用；第二阶段是对社会经济支持进行家庭随机对照评估的设计、实施和评估，以改善预防性治疗的可及性、提高结核病治愈率并减轻灾难性费用的影响。第一阶段表明，结核病仍然是贫困人口的疾病——对于受结核病影响的贫困家庭来说，“免费”结核病治疗难以承受，而产生灾难性费用与耐多药结核病一样，会导致许多不良结核病治疗结果（包括死亡、治疗失败、失访和结核病复发）。第二阶段表明，在接受社会经济支持的受结核病影响家庭中，家庭接触者更有可能开始并坚持结核病预防性治疗，结核病患者更有可能治愈，家庭产生灾难性费用的可能性更小。在秘鲁贫困的棚户区，贫困仍然与结核病紧密相连，产生灾难性费用预示着不良的结核病治疗结果。一种新型的社会经济支持干预措施增加了结核病预防性治疗的采用率，提高了结核病治疗成功率，并降低了灾难性费用。目前，一项名为“社会经济干预预防结核病社区随机评估”（CRESIPT）的研究正在评估该干预措施对结核病控制的影响。
