Impact of community-based adherence support on treatment outcomes for tuberculosis, leprosy and HIV/AIDS-infected individuals in post-Ebola Liberia

Background: Partners In Health (PIH) committed to improving health care delivery in Maryland County, Liberia following the Ebola epidemic by employing 71 community health workers (CHWs) to provide treatment support to tuberculosis (TB), HIV and leprosy patients. PIH simultaneously deployed a socioeconomic assistance program with three core components: transportation reimbursement to clinics; food support; and additional social assistance in select cases. Objective: This study aimed to evaluate how a CHW program for community treatment support and addressing socioeconomic barriers to care can impact patient outcomes in a post-conflict and post-epidemic context. Methods: Retrospective observational study utilizing registry data from 513 TB, 447 HIV and 75 leprosy patients at three health facilities in Maryland County, Liberia. Treatment coverage and clinical outcomes for patient cohorts enrolled in the pre-intervention period (January 2015 to June 2015) and the post-intervention period (July 2015 to July 2017) are compared using logistic regression analyses. Results: TB treatment coverage increased from 7.7% pre-intervention to 43.2% (p < 0.001) post-intervention and lost to follow-up (LTFU) rates decreased from 9.5% to 2.1% (p = 0.003). ART treatment coverage increased 3.8 percentage points (p = 0.03), with patient retention improving 63.9% to 86.1% (p < 0.001); a 6.0 percentage point decrease in HIV LTFU was also observed (p = 0.21). Despite an 84.3% treatment success rate observed for leprosy patients, pre-intervention data was largely unavailable and statistical significance could not be reached for any treatment outcomes pre-post intervention. Conclusions: The PIH approach to CHW community treatment support in Liberia demonstrates how, with the right inputs, excellent clinical outcomes are possible even in post-conflict and post-epidemic contexts. Care should be taken to position and support CHWs so that they have the opportunity to succeed, including full integration and recognition within the system, and the addition of clinical system improvements and social supports that are too often dismissed as unsustainable.