Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study

Area of Science:

• Public Health
• Infectious Diseases
• Epidemiology

Background:

• Nigeria offers free drug-resistant tuberculosis (DR-TB) care since 2011, yet struggles with low case notification and treatment rates.
• Despite improvements, only 11% of estimated DR-TB cases were diagnosed and 9% treated in 2018.

Purpose of the Study:

• To describe the Nigerian DR-TB care cascade from 2013 to 2017.
• To identify factors influencing gaps in DR-TB care access and treatment initiation.

Main Methods:

• A mixed-method design combining quantitative (national databases, WHO estimates) and qualitative (interviews, focus groups) data.
• Analysis of a 5-year care cascade and Fisher's exact test for patient/provider variables; thematic analysis of 57 qualitative interviews.

Main Results:

• Significant increases in DR-TB care access were observed, but substantial gaps remain: 80% lacked testing, 75% of tested were undiagnosed, 36% diagnosed did not start treatment, and 23% of those treated did not complete it.
• Children and patients in Northern Nigeria had lower odds of completing treatment; males had higher odds.
• Barriers included lack of awareness, family interference, low index of suspicion, limited diagnostics, and healthcare worker shortages.

Conclusions:

• Gains in DR-TB diagnostics and treatment are undermined by inadequate service access, with major losses occurring before treatment initiation.
• Urgent interventions are needed to address identified gaps, improve care continuity, enhance service delivery, and strengthen TB control in Nigeria.