Factors Associated with the Abandonment of Tuberculosis Treatment in Brazil: A Systematic Review

ABSTRACT Background: Tuberculosis (TB) is a chronic infectious disease caused by Mycobacterium tuberculosis. In Brazil, TB is a public health problem, and the treatment dropout rate contributes to it. Methods: This systematic review investigated the factors associated with TB treatment dropout in Brazil using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. The databases used were Bireme, Scopus, PubMed, Medline, Pan-American Health Organization (PAHO), and Latin-American and Caribbean Literature on Health Sciences (LILACS). The search was conducted on May 16, 2021. Nine articles were reviewed, and all were published within the last 5 years in English, Spanish, or Portuguese. Results: The sample sizes in the studies ranged from 148 to 77,212 individuals, and the studies enrolled only adult patients (aged 18-59 years) in Brazil. Evidence suggests that the significant risk factors associated with TB treatment dropout are male sex, black race/ethnicity, age between 19 and 49 years, human immunodeficiency virus (HIV) co-infection, low education (<8 years), use of alcohol and illicit drugs, and unsupervised treatment. This study’s limitations were the small number of articles published on this topic with stronger study designs, use of secondary data sources in most articles, and a moderate to high risk of bias in most papers. Conclusions: There was a significant association between abandonment of TB treatment and HIV/acquired immunodeficiency syndrome co-infection; socioeconomic factors (low education and homelessness); use of alcohol, tobacco, and illicit drugs; and failure to use directly observed treatment. These results can guide more efficient measures to prevent dropout.


Retrospective cohort
A total of 2079 individuals were selected. The mean age was 40.32 (15.19) years, with a slight predominance of men (56%). Most had a monthly income of less than three minimum wages (70.6%). The predominant clinical form of TB was pulmonary, and most participants had attended high school. There were 24 HIV-infected patients, and 57% used antiretroviral drugs during the TB treatment. Culture confirmed most TB cases.
A low level of education (incomplete elementary school) (OR 2.589; CI 1.152-5.821), the use of non-injectable drugs (OR 3; CI 1.308-6.884), and interruption of treatment because of adverse reactions (OR 6.3; CI 1. 809-21.948). The logistic model showed good discrimination with a ROCAUC of 0.81 and a 2 of 0.29.

Arroyo et. al , 2019 [17] Predictive model of unfavorable outcomes for MDR-TB Retrospective cohort
Regarding all cases diagnosed with MDR-TB between 2006 and 2015 in the state of São Paulo on the notification system (TBWeb), the study data was composed of 802 patients of MDR-TB (after filtering the duplicate notifications). Most were white (44.6%), followed by black/brown (33.3%), aged between 30-59 years (66.3%), of which 70% were male, and 44.1% had less than seven years of education. About 13% were diagnosed with AIDS and 13% with DM. About 22.8% reported alcoholism, and 12% used illicit drugs. Of all participants, 76% were undergoing supervised treatment.

Performance of centralized versus decentralized tuberculosis treatment services in Southern Brazil, 2006-2015
Retrospective cohort Evaluated patients were treated for pulmonary TB in the cities of Florianópolis and São José, using two data sources, each analyzing a different period. Data from the ten years (2006 to 2015) were gotten from the SINAN, available on the TABNET platform of the DIVE / SC, and a prospective cohort study was carried out with patients with culture-confirmed pulmonary TB who started treatment between 2014 and 2015. Of the 2309 cases evaluated (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015), 207 patients were interviewed from 2014 to 2015 in Florianópolis and São José-SC. The majority in both cities were men (66.9 and 63.8, respectively), with less than seven years of education (71.8 and 60.2), aged 25-34 years (32.3%) for Florianópolis, and > 45 years (34.9) for São José. In both cities, over 60% were smokers; 45.9% used illicit drugs in Florianópolis while in São José, this percentage did not reach 30%.
Regarding sociodemographic indicators, the only significant differences observed between the two populations were the proportion of illicit drug users (p = 0.02) and the proportion of homeless patients (p = 0.03), which were predominant indicators in Florianopolis. For patients who started treatment for TB in Florianópolis, where the UBS provided care, the treatment success rate was 22% lower (95% confidence interval = 9-33%), and the probability of treatment dropout was 2.41 times higher (95% confidence interval = 1.21-4.78) when compared to patients who started treatment in São José, where care was provided in the outpatient clinic. The TB treatment dropout rate (45%, 95% CI 12-90%) was also higher in the municipality with decentralized care. During the twoyear follow-up, significant differences were found between patients in centralized and decentralized care regarding treatment success (  Loss to follow-up represented 18.21%, which was prevalent among men (20.03%), blacks (20.34%) and people with brown skin color (19.55%), people aged 20-39 years (21.87%), and people with a few years of education. Individuals who lived in urban areas (19.64%), those who restarted treatment after loss to follow-up (58.13%), and those with pulmonary TB (19.08%) had a higher dropout rate. People with AIDS (42.33%), mental illness (36.82%), alcohol use (31.05%), drug use (39.39%), or smoking (26.54%) had higher negligence than individuals without these features. Bivariate logistic regression revealed that people who were male, darkskinned, aged between 20 and 39 years old, had no or only a few years of education, were urban dwellers or homeless, had pulmonary TB, reentered after treatment dropout, had AIDS or a mental disorder, used alcohol or illicit drugs, and smoked were more likely to drop out. The dropout rate was higher in men (14.3%), in the age groups from 20 to 39 years old (17.6%), and in those with incomplete primary school education (14.9%). DOT was performed in 52% of cases, with lower dropout rates (9.0%) and death (6.0%