title: Home-Based and Facility-Based Directly Observed Therapy of Tuberculosis Treatment under Programmatic Conditions in Urban Tanzania.
abstract: BACKGROUND
  Decentralization of Directly Observed Treatment (DOT) for tuberculosis (TB) to the community (home-based DOT) has improved the coverage of TB treatment and reduced the burden to the health care facilities (facility-based DOT). We aimed to compare TB treatment outcomes in home-based and facility-based DOT under programmatic conditions in an urban setting with a high TB burden.
  
  
  METHODS
  A retrospective analysis of a cohort of adult TB patients (≥15 years) routinely notified between 2010 and 2013 in two representative TB sub-districts in the Temeke district, Dar es Salaam, Tanzania. We assessed differences in treatment outcomes by calculating Risk Ratios (RRs). We used logistic regression to assess the association between DOT and treatment outcomes.
  
  
  RESULTS
  Data of 4,835 adult TB patients were analyzed, with a median age of 35 years, 2,943 (60.9%) were men and TB/HIV co-infection prevalence of 39.9%. A total of 3,593 (74.3%) patients were treated under home-based DOT. Patients on home-based DOT were more likely to die compared to patients on facility-based DOT (RR 2.04, 95% Confidence Interval [95% CI]: 1.52-2.73), and more likely to complete TB treatment (RR 1.14, 95% CI: 1.06-1.23), but less likely to have a successful treatment outcome (RR 0.94, 95% CI: 0.92-0.97). Home-based DOT was preferred by women (adjusted Odds Ratio [aOR] 1.55, 95% CI: 1.34-1.80, p<0.001), older people (aOR 1.01 for each year increase, 95% CI: 1.00-1.02, p = 0.001) and patients with extra-pulmonary TB (aOR 1.45, 95% CI: 1.16-1.81, p = 0.001), but less frequently by patients on a retreatment regimen (aOR 0.12, 95% CI: 0.08-0.19, p<0.001).
  
  
  CONCLUSIONS
  TB patients under home-based DOT had more frequently risk factors of death such as older age, HIV infection and sputum smear-negative TB, and had higher mortality compared to patients under facility-based DOT. Further operational research is needed to monitor the implementation of DOT under programmatic conditions.
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.|Swiss Tropical and Public Health Institute, Basel, Switzerland.|University of Basel, Basel, Switzerland.
authors: Francis
authors: http://orcid.org/0000-0001-8989-6832
authors: F
authors: Mhimbira
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.|Swiss Tropical and Public Health Institute, Basel, Switzerland.|University of Basel, Basel, Switzerland.
authors: Jerry
authors: J
authors: Hella
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors: Thomas
authors: T
authors: Maroa
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors: Shadrack
authors: S
authors: Kisandu
authors: National TB and Leprosy Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania.
authors: Magreth
authors: M
authors: Chiryamkubi
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.|Swiss Tropical and Public Health Institute, Basel, Switzerland.|University of Basel, Basel, Switzerland.
authors: Khadija
authors: K
authors: Said
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.|Swiss Tropical and Public Health Institute, Basel, Switzerland.|University of Basel, Basel, Switzerland.
authors: Grace
authors: G
authors: Mhalu
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors: Abdallah
authors: A
authors: Mkopi
authors: National TB and Leprosy Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania.
authors: Beatrice
authors: B
authors: Mutayoba
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.|Swiss Tropical and Public Health Institute, Basel, Switzerland.|University of Basel, Basel, Switzerland.
authors: Klaus
authors: K
authors: Reither
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland.|University of Basel, Basel, Switzerland.
authors: Sébastien
authors: S
authors: Gagneux
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.|Swiss Tropical and Public Health Institute, Basel, Switzerland.|University of Basel, Basel, Switzerland.|Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
authors: Lukas
authors: L
authors: Fenner
mesh_terms: D000293:Adolescent; D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use*; D060085:Coinfection / Q000188:drug therapy* / Q000453:epidemiology; D023801:Directly Observed Therapy / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D015497:HIV-1 / Q000187:drug effects; D006268:Health Facilities; D006699:Home Care Services; D006801:Humans; D008297:Male; D008875:Middle Aged; D018802:Patient-Centered Care; D015995:Prevalence; D012189:Retrospective Studies; D013636:Tanzania / Q000453:epidemiology; D016896:Treatment Outcome; D014376:Tuberculosis / Q000188:drug therapy* / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000995:Antitubercular Agents