École de santé publique de l'Université de Montréal (ESPUM), Montréal, Quebec, Canada
Centre de recherche en santé publique, Université de Montréal (CReSP), Montréal, Quebec, Canada.
BMJ Glob Health. 2020 Jul;5(7). doi: 10.1136/bmjgh-2019-002280.
Drug-resistant tuberculosis burdens fragile health systems in sub-Saharan Africa (SSA), complicated by high prevalence of HIV. Several African countries reported large gaps between estimated incidence and diagnosed or treated cases. Our review aimed to identify barriers and facilitators influencing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in SSA, which is necessary to develop effective strategies to find the missing incident cases and improve quality of care.
Using an integrative design, we reviewed and narratively synthesised qualitative, quantitative and mixed-methods studies from nine electronic databases: Medline, Global Health, CINAHL, EMBASE, Scopus, Web of Science, International Journal of Tuberculosis and Lung Disease, PubMed and Google Scholar (January 2006 to June 2019).
Of 3181 original studies identified, 55 full texts were screened, and 29 retained. The studies included were from 6 countries, mostly South Africa. Barriers and facilitators to DR-TB care were identified at the health system and patient levels. Predominant health system barriers were laboratory operational issues, provider knowledge and attitudes and information management. Facilitators included GeneXpert MTB/RIF (Xpert) diagnosis and decentralisation of services. At the patient level, predominant barriers were patients being lost to follow-up or dying due to lengthy diagnostic and treatment delays, negative public sector care perceptions, family, work or school commitments and using private sector care. Some patient-level facilitators were HIV positivity and having more symptoms.
Case detection and treatment for DR -TB in SSA currently relies on individual patients presenting voluntarily to the hospital for care. Specific interventions targeting identified barriers may improve rates and timeliness of detection and treatment.
耐多药结核病使撒哈拉以南非洲（SSA）脆弱的卫生系统负担沉重，加之艾滋病毒高发，情况更为复杂。一些非洲国家报告说，估计的发病率与确诊或治疗病例之间存在很大差距。我们的综述旨在确定影响 SSA 耐多药结核病（DR-TB）诊断和治疗的障碍和促进因素，这对于制定发现缺失病例和提高护理质量的有效策略是必要的。
我们采用综合设计，从 9 个电子数据库（Medline、全球健康、CINAHL、EMBASE、Scopus、Web of Science、国际结核病和肺部疾病杂志、PubMed 和 Google Scholar）中审查和叙述性综合了定性、定量和混合方法研究：2006 年 1 月至 2019 年 6 月）。
在最初确定的 3181 项研究中，有 55 篇全文被筛选，29 篇被保留。这些研究来自 6 个国家，主要来自南非。在卫生系统和患者层面都发现了 DR-TB 护理的障碍和促进因素。主要的卫生系统障碍是实验室运营问题、提供者的知识和态度以及信息管理。促进因素包括 GeneXpert MTB/RIF（Xpert）诊断和服务的分散化。在患者层面，主要障碍是由于诊断和治疗延误时间长，患者失访或死亡，对公共部门护理的负面看法，家庭、工作或学校的承诺以及使用私营部门护理。一些患者层面的促进因素是 HIV 阳性和更多的症状。
目前，SSA 耐多药结核病的病例发现和治疗依赖于自愿到医院就诊的个体患者。针对已确定障碍的具体干预措施可能会提高检测和治疗的速度和及时性。
