Towards patient centred care: Integrating TB and respiratory services in Africa

Background: The burden of tuberculosis (TB) and chronic respiratory disease (CRD) remains unacceptably high in low and middle income countries (LMICs), with 10.6 million incident cases of TB disease in 2022, and respiratory diseases amongst the leading causes of morbidity and mortality globally. TB and CRDs are closely linked in LMICs. Both are conditions of deprivation, with risk factors including smoking and occupational exposures.

Both are highly stigmatised, and lead to long-term disability, health seeking, and loss of income. TB is itself a direct cause of lung damage with up to half of pulmonary TB survivors left with residual post-TB lung disease (PTLD). The management of PTLD and CRDs require similar interventions including inhaled therapies and pulmonary rehabilitation.

Patients present with similar symptoms of cough and breathlessness, and are largely routed through TB services as people with presumptive TB (PPTB), but after assessment over half will not have TB disease.

Despite this close relationship, TB and CRD care are delivered separately in LMICs. TB is managed via well-resourced vertical National TB Programmes, whilst respiratory care is provided via less well defined and poorly resourced health systems. The absence of integrated TB-respiratory care means that TB patients receive inadequate respiratory support, whilst those with CRDs remain undiagnosed, and are often incorrectly treated with recurrent courses of antibiotics and TB medication for ongoing symptoms.

There are strong calls from TB patients and policy makers for integrated TB-respiratory care, and this is particularly important given the emerging burden of non-communicable diseases in LMICs. Our previous work shows that the absence of models of care remains a key barrier to implementation.

Aims: In this four-year research programme we will develop a framework for the implementation and evaluation of integrated TB-respiratory care, for the diagnosis, prevention, and management of respiratory diseases across the TB care cascade in urban settings in Kenya, Tanzania and Nigeria. This work is rooted in previous stakeholder engagement work, informed by MRC guidance for complex health intervention development, and builds on two previous NIHR grants (16/136/35 and 130307).

Scientific objectives include: 1. To develop a conceptual framework for integrated TB-respiratory care

2. To describe the epidemiology of non-TB respiratory disease amongst PPTB, and to propose a respiratory diagnostic pathway for use within TB services.

3. To understand existing approaches to respiratory exposures and disease amongst TB patients and providers, and to co-develop counselling and education tools to support respiratory care.

4. To understand the health system needs, challenges, and implications of integrated TB-respiratory care, and to propose novel frameworks for integrated care.

5. To understand the economic costs and benefits of integrated approaches to TB-respiratory care, and to develop a value framework for service evaluation. Broader research objectives include: 1. To map and engage with stakeholders and community members with interest or influence in TB and respiratory care.

2. To deliver sustainable research capacity strengthening in each study site.

Outcomes and Impact: The proposed framework and evaluation tools will be shared with policy makers to inform guideline development and operational research, and will lead to a funding application for a multi-site randomised control trial to evaluate the impact of integrated TB-respiratory care in Africa.