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BACKGROUND: Although culture remains the standard for TB diagnosis, 15-20% of patients diagnosed and treated for TB are culture-negative. We explored clinical characteristics, risk factors and treatment outcomes for culture-negative TB in a Peruvian cohort.METHODS: We recruited 4,500 index TB patients and 10,160 household contacts in Lima, Peru, and enrolled 692 secondary patients diagnosed with TB during follow-up of household contacts. We analyzed smear and culture status, sociodemographic factors, clinical characteristics and TB treatment outcomes to compare culture-negative and positive patients.RESULTS: Of the 4,880 adult patients, 915 (18.8%) were culture-negative. Culture-negative patients were less likely to report symptoms of TB disease and disease of longer duration. A multivariate analysis showed no statistically significant difference in loss to follow-up, treatment failure or recurrence between the culture-negative and -positive groups but a higher rate of death among culture-negative patients with an adjusted OR of 1.65 (95% CI 1.05-2.60). In a multivariate analysis of determinants of culture negativity, older age, substance use and being a secondary case were associated with culture status.CONCLUSIONS: More recognition and awareness of culture-negative TB is key for early and correct diagnosis to reduce transmission and improve treatment outcomes.
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Tuberculosis Pulmonar , Adulto , Humanos , Tuberculosis Pulmonar/diagnóstico , Factores de Riesgo , Resultado del Tratamiento , Perú/epidemiología , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Timely diagnosis and treatment of pediatric tuberculosis (TB) is critical to reducing mortality but remains challenging in the absence of adequate diagnostic tools. Even once a TB diagnosis is made, delays in treatment initiation are common, but for reasons that are not well understood.METHODS: To examine reasons for delay post-diagnosis, we conducted semi-structured interviews with Ministry of Health (MoH) physicians and field workers affiliated with a pediatric TB diagnostic study, and caregivers of children aged 0-14 years who were diagnosed with pulmonary TB in Lima, Peru. Interviews were analyzed using systematic comparative and descriptive content analysis.RESULTS: We interviewed five physicians, five field workers and 26 caregivers with children who initiated TB treatment < 7 days after diagnosis (n = 15) or who experienced a delay of ≥7 days (n = 11). Median time in delay from diagnosis to treatment initiation was 26 days (range 7-117). Reasons for delay included: health systems challenges (administrative hurdles, medication stock, clinic hours), burden of care on families and caregiver perceptions of disease severity.CONCLUSION: Reasons for delay in treatment initiation are complex. Interventions to streamline administrative processes and tools to identify and support families at risk for delays in treatment initiation are urgently needed.
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Tuberculosis Pulmonar , Tuberculosis , Adolescente , Cuidadores , Niño , Preescolar , Diagnóstico Tardío , Humanos , Lactante , Recién Nacido , Perú/epidemiología , Tuberculosis/diagnóstico , Tuberculosis/tratamiento farmacológico , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/tratamiento farmacológicoRESUMEN
BACKGROUND: Mental health is an important factor in responding to natural disasters. Observations of unmet mental health needs motivated the subsequent development of a community-based mental health intervention following one such disaster affecting Peru in 2017. METHODS: Two informal human settlements on the outskirts of Lima were selected for a mental health intervention that included: (1) screening for depression and domestic violence, (2) children's activities to strengthen social and emotional skills and diminish stress, (3) participatory theater activities to support conflict resolution and community resilience, and (4) community health worker (CHW) accompaniment to government health services. RESULTS: A total of 129 people were screened across both conditions, of whom 12/116 (10%) presented with depression and 21/58 (36%) reported domestic violence. 27 unique individuals were identified with at least one problem. Thirteen people (48%) initially accepted CHW accompaniment to government-provided services. CONCLUSIONS: This intervention provides a model for a small-scale response to disasters that can effectively and acceptably identify individuals in need of mental health services and link them to a health system that may otherwise remain inaccessible.
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BACKGROUND: An estimated 19-25% of perinatal women in low- and middle-income countries are affected by depression which, untreated, is associated with multiple health problems for mothers and children. Nonetheless, few perinatal women have access to depression care. The Thinking Healthy Programme (THP), promoted by the World Health Organization (WHO), is an evidence-based, non-specialist delivered depression intervention that addresses this care gap. However, the WHO THP manual explains intervention delivery but not the antecedents to implementation. Here, we describe a principled, planned approach leading to the implementation of THP in Lima, Peru by the non-profit organization Socios En Salud with community health workers (CHW) to inform its implementation in other settings. METHODS: The Replicating Effective Programs (REP) framework guided THP implementation, following four phases: (I) pre-conditions; (II) pre-implementation; (III) implementation; and (IV) maintenance and evolution. This paper centers on REP phases I and II, including (1) documented high perinatal depression rates in Peru; (2) designation of perinatal depression as a government priority; (3) THP Implementation Team orientation and training; (4) data collection plan development; (5) public health system coordination; (6) CHW selection and training; and (7) THP launch. RESULTS: Between December 2016 and March 2017, a THP training program was developed and seven CHW were trained to deliver the intervention to 10 perinatal women, the first of whom was enrolled on 17 April 2017. CONCLUSIONS: THP was rapidly implemented by a community-based organization with no prior experience in delivering non-specialist perinatal depression care. The steps followed may inform the implementation of THP in other settings.
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BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) regimens often contain pyrazinamide (PZA) even if susceptibility to the drug has not been confirmed. This gap is due to the limited availability and reliability of PZA susceptibility testing. OBJECTIVES: To estimate the prevalence of PZA resistance using the Wayne assay among TB patients in Lima, Peru, to describe characteristics associated with PZA resistance and to compare the performance of Wayne with that of BACTEC™ MGIT™ 960. METHODS: PZA susceptibility using the Wayne assay was tested in patients diagnosed with culture-positive pulmonary TB from September 2009 to August 2012. Factors associated with PZA resistance were evaluated. We compared the performance of the Wayne assay to that of MGIT 960 in a convenience sample. RESULTS: The prevalence of PZA resistance was 6.6% (95%CI 5.8-7.5) among 3277 patients, and 47.7% (95%CI 42.7-52.6) among a subset of 405 MDR-TB patients. In multivariable analysis, MDR-TB (OR 86.0, 95%CI 54.0-136.9) and Latin American-Mediterranean lineage (OR 3.40, 95%CI 2.33-4.96) were associated with PZA resistance. The Wayne assay was in agreement with MGIT 960 in 83.9% of samples (κ 0.66, 95%CI 0.56-0.76). CONCLUSION: PZA resistance was detected using the Wayne assay in nearly half of MDR-TB patients in Lima. This test can inform the selection and composition of regimens, especially those dependent on additional resistance.
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Antituberculosos/administración & dosificación , Pirazinamida/administración & dosificación , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Tuberculosis Pulmonar/tratamiento farmacológico , Adolescente , Adulto , Anciano , Estudios de Cohortes , Farmacorresistencia Bacteriana , Femenino , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Análisis Multivariante , Perú , Prevalencia , Estudios Prospectivos , Reproducibilidad de los Resultados , Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Tuberculosis Resistente a Múltiples Medicamentos/microbiología , Tuberculosis Pulmonar/epidemiología , Tuberculosis Pulmonar/microbiología , Adulto JovenRESUMEN
SETTING: A safe, effective vaccine would improve tuberculosis (TB) control worldwide. Extensive community engagement will be essential to ensure the interest and participation of populations at highest risk. OBJECTIVE/METHOD: To inform the potential implementation of efficacy studies, we assessed TB knowledge, attitudes towards licensed vaccines and willingness to participate in future TB vaccine efficacy trials among 262 household contacts of 79 recently diagnosed pulmonary TB cases in Lima, Peru. RESULTS: Overall knowledge of TB was low. Only 41.6% of household contacts perceived themselves as being at high risk of acquiring TB. Slightly above half (54.2%) indicated willingness to participate in a TB vaccine trial. After clustered analysis adjusting for homogeneity among families, willingness to enroll was associated with belief that receiving all recommended vaccinations is important (adjusted OR [aOR] 3.28, P = 0.016), desire to know more about TB risk factors and clinical trials (aOR 2.60, P = 0.004), older age (aOR 1.02, P = 0.027) and TB knowledge (aOR 0.05, P = 0.039). CONCLUSION: Barriers to participation in TB vaccine trials exist among individuals at high risk for TB. Targeted education about TB risk factors, TB transmission and education about the clinical trial process will be critical for laying the groundwork for future vaccine trials.
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Conocimientos, Actitudes y Práctica en Salud , Vacunas contra la Tuberculosis/administración & dosificación , Tuberculosis Pulmonar/prevención & control , Tuberculosis/prevención & control , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Ensayos Clínicos como Asunto/psicología , Análisis por Conglomerados , Trazado de Contacto , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud/estadística & datos numéricos , Perú , Factores de Riesgo , Encuestas y Cuestionarios , Tuberculosis/transmisión , Tuberculosis Pulmonar/transmisión , Adulto JovenRESUMEN
SETTING: Observational cohort study in Lima, Peru. OBJECTIVE: To determine the association between exposure to a smoking tuberculosis (TB) case and latent tuberculous infection (LTBI). METHOD: Between September 2009 and August 2012, we identified 2132 patients with drug-susceptible TB and their 2054 child household contacts. Data were collected on active and secondhand smoking status and other risk factors for infection specific to the index case, the household and the exposed contacts. Contacts underwent a tuberculin skin test (TST) to determine their tuberculous infection status at baseline, 6-month and 12-month follow-up. We estimated the association between exposure to a smoking index case and LTBI using a modified Poisson regression model. RESULTS: The 21 children (age â©¿15 years) exposed to smoking index TB patients were more likely to be TST-positive at baseline (RR 2.64, 95%CI 1.78-3.91), by 6 months (RR 1.91, 95%CI 1.40-2.60) and by 12 months (RR 1.48, 95%CI 1.07-2.06), than those who were not exposed. TST positivity among children at these time points did not vary with secondhand smoke exposure. CONCLUSIONS: TB patients who smoke may be more likely to transmit infection to their contacts. Interventions designed to reduce smoking among TB patients may minimise further spread of the disease.
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Tuberculosis Latente/epidemiología , Fumar/epidemiología , Contaminación por Humo de Tabaco , Tuberculosis/transmisión , Adolescente , Adulto , Niño , Preescolar , Estudios de Cohortes , Trazado de Contacto , Femenino , Estudios de Seguimiento , Humanos , Lactante , Tuberculosis Latente/diagnóstico , Masculino , Persona de Mediana Edad , Perú/epidemiología , Distribución de Poisson , Factores de Riesgo , Factores de Tiempo , Prueba de Tuberculina , Adulto JovenRESUMEN
This study examined pre-exposure prophylaxis (PrEP) acceptability among female sex workers, male-to-female transgendered persons and men who have sex with men in Lima, Peru. Focus groups explored social issues associated with PrEP acceptability and conjoint analysis assessed preferences among eight hypothetical PrEP scenarios with varying attribute profiles and their relative impact on acceptability. Conjoint analysis revealed that PrEP acceptability ranged from 19.8 to 82.5 out of a possible score of 100 across the eight hypothetical PrEP scenarios. Out-of-pocket cost had the greatest impact on PrEP acceptability (25.2, P < 0.001), followed by efficacy (21.4, P < 0.001) and potential side-effects (14.7, P < 0.001). Focus group data supported these findings, and also revealed that potential sexual risk disinhibition, stigma and discrimination associated with PrEP use, and mistrust of health-care professionals were also concerns. These issues will require careful attention when planning for PrEP roll-out.
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Quimioprevención/estadística & datos numéricos , Infecciones por VIH/prevención & control , Aceptación de la Atención de Salud/estadística & datos numéricos , Adulto , Femenino , Grupos Focales , Homosexualidad Masculina , Humanos , Masculino , Perú , Trabajo Sexual , TravestismoRESUMEN
This study assessed lubricant use during receptive anal intercourse (RAI) among Peruvian men who have sex with men (MSM) and willingness to use a hypothetical rectal microbicide (RM) formulated as a lubricant to prevent HIV infection. Data were collected from 843 Peruvian MSM for the 2008 HIV Sentinel Surveillance using a computerized self-interview. Half of the participants reported using a lubricant with their last sex partner during RAI, while 77% were willing to use a lubricant to prevent HIV transmission. Lubricant use with last sex partner was significantly associated with unprotected RAI (odds ratio [OR] 1.59, 95% confidence interval [CI], 1.23, 2.05; P < 0.001) and willingness to use a future lubricant RM (OR 1.56, 95% CI: 1.24, 1.95; P < 0.001). This study provides information on the behaviours associated with lubricant use and non-use among MSM practicing RAI in Peru that should inform future RM studies in Peru and other Latin American countries.