Pre-treatment loss to follow-up and associated factors among drug-resistant tuberculosis patients diagnosed in Wakiso district, central Uganda

Tuberculosis ranks among the top ten causes of death worldwide. The Sub-Saharan African region faces increasing trends of Drug-Resistant Tuberculosis (DR-TB), further complicating the existing efforts for prevention, control, and eradication. Pre-treatment loss to follow-up (LTFU) among diagnosed DR-TB patients also signifies a setback in the timely prevention of disease progression and transmission, especially in low-resource settings. This study assessed the magnitude of and factors associated with pre-treatment LTFU among DR-TB patients within Wakiso district, central Uganda. A sequential explanatory study design was adopted to analyze electronic case-based surveillance (eCBSS) data between 2017 to 2022 from the Ministry of Health, Uganda. Participants for qualitative data comprised of six (6) key informant interviews and 2 focus group discussions among health workers and DR-TB patients respectively. Out of the 972 records retrieved from the eCBSS system for patients treated at Mulago National Referral Hospital from 2017 to 2022; 253 were analyzed. The majority of the participants, 62% (157/253), were male. The median age of study participants was 34 years (range: 18- 85). The prevalence of pretreatment LTFU was 13.4% (34/253). The qualitative findings reinforced and provided context to the quantitative results, revealing how behavioral, social, and system-level factors contribute to pre-treatment loss to follow-up (LTFU) among DR-TB patients. Significant associations were observed in patients who lacked a recorded telephone contact in TB register (adjusted PR = 0.47, 95% CI: 0.27-0.80) and those without documented home address (adjusted PR = 0.52, 95% CI: 0.27-0.97); qualitatively, this was linked to patients' fear of stigma, lack of trust in the health system, and unstable living conditions, leading them to avoid being traced. The analysis also showed that tobacco use (adjusted PR = 1.96, 95% CI: 1.00-3.87) and illicit drug use (adjusted PR = 4.00, 95% CI: 1.76-9.08) significantly increased the risk of LTFU, which was supported by narratives describing substance use as contributing to hopelessness and neglect of health. Furthermore, patients with a history of treatment failure had 2.4 times the risk of being lost to follow-up (adjusted PR = 2.40, 95% CI: 1.08-5.36), consistent with qualitative reports of discouragement, denial, and lack of awareness about the severity of DR-TB. Relapse cases had 69% higher prevalence of loss to follow-up (adjusted PR = 1.69, 95% CI 0.78-3.70) compared to new cases. Although factors such as alcohol use and family support did not reach statistical significance in the quantitative model, they were prominent in the qualitative data, suggesting under-recognized barriers related to psychosocial distress and poverty. Together, these findings demonstrate a strong convergence between data strands while highlighting that some influential factors particularly social and psychological may be underrepresented in routine health data. The study found a 13.4% prevalence of pre-treatment LTFU among DR-TB patients in Wakiso District. Quantitative analysis identified significant predictors, including lack of contact information, prior treatment failure, tobacco use, and illicit drug use, while protective factors included having a recorded home address and telephone contact recorded in relevant TB registers/electronic systems. These findings were reinforced by qualitative insights, which revealed that fear of stigma, denial of illness, substance abuse, poor health system responsiveness, and lack of social support contributed to patient disengagement. The integration of both data strands highlights the need for a patient-centered approach that strengthens communication, addresses behavioral health needs, and improves follow-up systems to reduce pre-treatment LTFU and improve DR-TB outcomes.