PREreview of Treatment outcomes of tuberculosis among people living with HIV/AIDS: A comparative assessment of primary and tertiary healthcare centres in Nasarawa State, Nigeria

Summary

This paper introduces a retrospective facility based study evaluating tuberculosis (TB) treatment outcomes of people living with HIV (PLWH) in Nasarawa State, Nigeria. The study compares treatment success rates (TSR) between primary and tertiary healthcare facilities and tries to determine predictors of successful outcomes. Data was taken from TB registers and treatment cards of 959 patients treated in the years 2016 through 2019. The TSR was found to be low (46.5%), with primary healthcare centers showing higher cure rates and tertiary centers showing higher rates of treatment failure, mortality, and loss to follow-up. Multivariate logistic regression found that receiving treatment at a tertiary facility predicted a higher likelihood of treatment success. The findings of the study suggest a need for stronger systems and adherence support, especially in tertiary healthcare facilities.

Major Issues

1. The study does not adjust for the increased chances that sicker patients who often have more complex needs are sent to tertiary hospitals, which could explain the higher rates of death, treatment failure, and loss to follow-up observed within these facilities. I recommend the authors to either stratify their analysis and/or mention these limitations in the limitations section of the paper.

2. The paper states that utilizing AFB or clinical judgment for diagnoses is correlated with greater treatment success rates in comparison to using GeneXpert. This may not be a fair comparison however as GeneXpert is more prevalent in tertiary healthcare facilities where the patients are in more critical conditions. The author should take this into account and further discuss this point when comparing the results of diagnostic methods for TB. The authors could also do an analysis stratified by diagnostic method and facility type.

3. The study discusses the data representing a decline in the treatment success rate from 68.8% to 57.6% by 2019  but does not give much context for this trend. To strengthen their analysis, they should provide some statistical evaluation. I suggest the authors further describe if the decline was statistically significant by conducting a formal trend analysis and report the statistical findings in comparing the groups. Additionally, providing contextual information on the potential factors of this decline would be very insightful to the readers as well to the policymakers and healthcare workers to provide proper intervention. 

1. The study makes two major claims in a manner that sounds as if they contradict each other; because of this, it is imperative that the authors use clear and plain language to discuss their findings. 

   1. For example: In the abstract the paper claims, “The rate of unsuccessful TB treatment is highest in tertiary healthcare facilities compared to PHC. However, being treated in the tertiary healthcare facility predicted successful treatment outcomes, while treatment failure, death, and loss to follow-up were highest in the tertiary healthcare facilities.” This statement is not entirely clear. The author should be more explicit in distinguishing these statements. Their first claim is that PHC’s are correlated with better overall outcomes as they have better patient retention and rates of treatment completion. Their second claim is that THC's predict better outcomes when patient’s actually complete treatment. However, this interpretation of the second claim is not explicitly stated or supported in the text. This leaves the reader having to make their own inferences on what they are exactly claiming from their linear regression analysis. 

Minor Issues

1. The paper appears to interchangeably use the phrases “successful treatment outcomes” and “treatment success rate.” The author should adopt consistent terminology throughout to minimize confusion. 

Suggestions

1. Future studies could include interviews to evaluate factors influencing adherence and follow-up.

2. The author could stratify patients based on severity of the disease and incorporate data of the baseline levels of disease such as their vitals to make more fair and effective comparisons on treatment outcomes.

3. The author could break down the treatment success outcome data into three components (cure, treatment completion, loss to follow-up) in order to better understand where policy or medical interventions are needed amongst the different facilities.

Conclusion

While the study provides valuable insights into TB treatment outcomes for PLWH, changes are necessary to make their comparisons between tertiary and primary healthcare centers appropriate. Understanding the difference in outcomes amongst primary and tertiary facilities brings to light important concerns that can be useful for policymakers and healthcare workers. A key confound in the study regarding sicker patients being at tertiary health care centers limit our takeaways from the data and results. This confound can not be addressed within the extent of their data. With this, it is recommended that further studies be conducted that control for disease severity and comorbidities to better assess the impact of facility type on treatment outcomes.  

Competing interests

The authors declare that they have no competing interests.

Use of Artificial Intelligence (AI)

The authors declare that they used generative AI to come up with new ideas for their review.