Brief Report: Differentiated Service Delivery Framework for People With Multidrug-Resistant Tuberculosis and HIV Coinfection

Introduction: For people living with HIV/AIDS, care is commonly delivered through differentiated service delivery (DSD). Although people with multidrug-resistant tuberculosis (MDR-TB) and HIV/AIDS experience severe treatment-associated challenges, there is no DSD model to support their treatment. In this study, we defined patterns of medication adherence and characterized longitudinal barriers to inform development of an MDR-TB/HIV DSD framework. Methods: Adults with MDR-TB and HIV initiating bedaquiline (BDQ) and receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa, were enrolled and followed through the end of MDR-TB treatment. Electronic dose monitoring devices measured BDQ and ART adherence. Longitudinal focus groups were conducted and transcripts analyzed thematically to describe discrete treatment stage-specific and cross-cutting treatment challenges. Results: Two hundred eighty-three participants were enrolled and followed through treatment completion (median 17.8 months [interquartile range 16.5-20.2]). Thirteen focus groups were conducted. Most participants (82.7%, 234/283) maintained high adherence (mean BDQ adherence 95.3%; mean ART adherence 85.5%), but an adherence-challenged subpopulation with <85% cumulative adherence (17.3%, 49/283) had significant declines in mean weekly BDQ adherence from 94.9% to 39.9% (P < 0.0001) and mean weekly ART adherence from 83.9% to 26.6% (P < 0.0001) over 6 months. Psychosocial, behavioral, and structural obstacles identified in qualitative data were associated with adherence deficits in discrete treatment stages and identified potential stage-specific interventions. Conclusions: A DSD framework for MDR-TB/HIV should intensify support for adherence-challenged subpopulations, provide multimodal support for adherence across the treatment course, and account for psychosocial, behavioral, and structural challenges linked to discrete treatment stages.