Hidden in Success: Gendered Patterns of Suboptimal Care Engagement Among TB Patients Who "Successfully" Completed Treatment in South Africa.

Abstract

Timeously completing tuberculosis (TB) treatment is key to optimal health outcomes. Suboptimal treatment refill patterns, even among those categorized as "treatment success," may portend unfavorable outcomes. Using patient-level medication refill data, latent-class mixed modelling was used to identify longitudinal trajectories of care engagement among TB patients achieving programmatic treatment success. Logistic regression was conducted to investigate participant-level characteristics associated with trajectory class membership. Among 548 participants, we identified three trajectories: Class 1 (consistent engagement; 84.1%), Class 2 (suboptimal engagement after 2 months; 7.7%) and Class 3 (suboptimal engagement from initiation; 8.2%). At treatment completion, Classes 1-3 accumulated 9.7 (95% CI: 7.4-11.8), 68.4 (60.4-76.9) and 55.5 (48.1-62.7) missed refill days, respectively. In gender-stratified models, men exhibited all three trajectories (83.1%, 7.4%, and 9.5%, respectively), and accumulated 10.6 [7.8-13.3], 61.0 [50.2-71.3], 62.31 [53.14-71.72] missed refill days, respectively. Women exhibited only Classes 1 and 3 (89.5% and 10.5%, respectively) and accumulated 12.1 [7.8-16.5] and 46.9 [33.3-61.6] missed refill days, respectively. Among men, prior TB (Class 2: aOR 7.44, 2.79-19.8; Class 3: aOR 2.78, 1.07-7.25) and HIV-negative status (Class 3: aOR 2.72, 1.13-6.54) were associated with suboptimal trajectories. Among women, prior TB was associated with suboptimal engagement (aOR 5.22, 1.11-24.44). Programmatic "treatment success" obscured heterogeneity in treatment refill patterns. Patient-centered counseling and gender-responsive interventions are needed to address treatment refill behaviors. Shorter regimens alone may not resolve suboptimal engagement, highlighting the need for flexible treatment strategies.