A prospective cohort study examined patterns of care engagement among adults with drug-susceptible pulmonary TB who were programmatically classified as having treatment success. The study used latent class trajectory modeling of medication refill data and was conducted from February 2021 to August 2022 in 21 government healthcare facilities in Buffalo City Metro Health District, Eastern Cape Province, South Africa.
The analysis included 548 of 657 enrolled adults (83.4%) who were classified as cured or treatment completed. Eligible participants were aged 18 years or older, spoke English or isiXhosa, lived in a participating clinic catchment area, and gave informed consent; people with extrapulmonary TB without lung involvement or drug-resistant TB were excluded. Participants completed staff-administered questionnaires on sociodemographic factors, health status, PHQ-9 depression symptoms, AUDIT alcohol use, GAD-7 anxiety symptoms, TB knowledge, attitudes, and beliefs. Refill dates, scheduled visits, treatment start dates, and outcomes were abstracted from medical records. The main outcome was cumulative missed TB medication refill days during treatment, analyzed using latent class trajectory modeling. Level of evidence: prospective observational cohort.
Among those with treatment success, median age was 38 years (IQR, 30 to 47), 67% were men, 78.3% were unemployed, 46.2% were living with HIV, 28.1% had previous TB, and 38.9% screened positive for moderate to severe depression. Three overall engagement trajectories were identified: consistent engagement (84.1%), suboptimal engagement after 2 months (7.7%), and suboptimal engagement from onset (8.2%). By treatment completion, predicted cumulative missed refill days were 9.68 (95% CI, 7.41 to 11.83), 68.42 (95% CI, 60.35 to 76.92), and 55.47 (95% CI, 48.05 to 62.66), respectively. Men had three classes, while women had two; overall suboptimal engagement was higher among men than women (16.9% vs 10.5%). Recent TB within the past 2 years was strongly associated with suboptimal engagement overall (aOR, 4.38; 95% CI, 2.29 to 8.36), among men, and among women. Among men, HIV-negative status was also associated with suboptimal from-initiation engagement (aOR, 2.72; 95% CI, 1.13 to 6.54).
In conclusion, many patients labeled as having TB treatment success still had meaningful refill delays, especially men and those with recent prior TB. Key limitations include use of refill timing as a proxy for adherence, restriction to patients classified as treatment success, and generalizability mainly to similar public-sector TB settings in South Africa.
Source: Medina-Marino A, Arua E, de Vos L, Fiphaza K, Bezuidenhout D, Ngcelwane N, Charalambous S, Daniels J. Hidden in Success: Gendered Patterns of Suboptimal Care Engagement Among Tuberculosis Patients Who “Successfully” Completed Treatment in South Africa. Clinical Infectious Diseases. 2025 Dec 19:ciaf714.
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