Preventing tuberculosis in people at high risk

Background Poverty drives TB rates but the current TB control approach is disproportionately biomedical. In 2015, the World Health Organisation’s End TB Strategy explicitly identified the need to address the social determinants of TB through socioeconomic interventions. However, evidence concerning poverty-reduction and costs-mitigation strategies is limited. My PhD research aimed to address this knowledge gap. Methods During this PhD, I aimed to develop as an independent researcher while addressing the social determinants of TB in impoverished shantytown communities of Callao, Peru, through integrated projects. The research was divided into two phases: 1) Final follow-up, data collection, analysis, and write-up of: a case-control study defining the TB-poverty association; an ecological study assessing poverty-related risk factors for TB infection and disease; and a cohort study identifying TB-related costs of TB-affected families and creating a clinically-relevant catastrophic costs threshold. 2) Conception, design, implementation, data collection, analysis, and write-up of a household-randomized controlled study of a socioeconomic intervention to improve TB cure and prevention. Results The first phase showed that TB remains a disease of people living in poverty, that “free” TB care was expensive for impoverished TB-affected families to afford, and that incurring catastrophic costs explained as many adverse outcomes as multi-drug resistant (MDR) TB. The second phase showed that, in households receiving the TB-specific socioeconomic intervention, TB-affected households were less likely to incur catastrophic costs, household contacts were more likely to start and adhere to TB preventive therapy, and TB patients were more likely to be cured. Conclusion In impoverished Peruvian shantytowns, poverty remains associated with TB and incurring catastrophic TB-related costs predicted adverse TB outcome. A novel TB-specific socioeconomic intervention reduced catastrophic costs and improved TB preventive therapy uptake and TB cure. The impact of the intervention on TB control will now be evaluated during the Community Randomized Evaluation of a Socioeconomic Intervention to Prevent TB (CRESIPT) study.Open Acces