{"doi":"10.1371/journal.pone.0252095","title":"Pathways to care and preferences for improving tuberculosis services among tuberculosis patients in Zambia: A discrete choice experiment","abstract":"BACKGROUND: Delays in the diagnosis of tuberculosis (TB) contribute to a substantial proportion of TB-related mortality, especially among people living with HIV (PLHIV). We sought to characterize the diagnostic journey for HIV-positive and HIV-negative patients with a new TB diagnosis in Zambia, to understand drivers of delay, and characterize their preferences for service characteristics to inform improvements in TB services. METHODS: We assessed consecutive adults with newly microbiologically-confirmed TB at two public health treatment facilities in Lusaka, Zambia. We administered a survey to document critical intervals in the TB care pathway (time to initial care-seeking, diagnosis and treatment initiation), identify bottlenecks and their reasons. We quantified patient preferences for a range of characteristics of health services using a discrete choice experiment (DCE) that assessed 7 attributes (distance, wait times, hours of operation, confidentiality, sex of provider, testing incentive, TB test speed and notification method). RESULTS: Among 401 patients enrolled (median age of 34 years, 68.7% male, 46.6% HIV-positive), 60.9% and 39.1% were from a first-level and tertiary hospital, respectively. The median time from symptom onset to receipt of TB treatment was 5.0 weeks (IQR: 3.6-8.0) and was longer among HIV-positive patients seeking care at a tertiary hospital than HIV-negative patients (6.4 vs. 4.9 weeks, p = 0.002). The time from symptom onset to initial presentation for evaluation accounted for the majority of time until treatment initiation (median 3.0 weeks, IQR: 1.0-5.0)-an important minority of 11.0% of patients delayed care-seeking ≥8 weeks. The DCE found that patients strongly preferred same-day TB test results (relative importance, 37.2%), facilities close to home (18.0%), and facilities with short wait times (16.9%). Patients were willing to travel to a facility up to 7.6 kilometers further away in order to access same-day TB test results. Preferences for improving current TB services did not differ according to HIV status. CONCLUSIONS: Prolonged intervals from TB symptom onset to treatment initiation were common, especially among PLHIV, and were driven by delayed health-seeking. Addressing known barriers to timely diagnosis and incorporating patients' preferences into TB services, including same-day TB test results, may facilitate earlier TB care engagement in high burden settings.","journal":"PLoS ONE","year":2021,"id":179702,"datarank":0.6322203905715176,"base_score":2.9444389791664403,"endowment":2.9444389791664403,"self_citation_contribution":0.44166584687496613,"citation_network_contribution":0.1905545436965514,"self_endowment_contribution":0.44166584687496613,"citer_contribution":0.1905545436965514,"corpus_percentile":null,"corpus_rank":null,"citation_count":18,"citer_count":9,"citers_with_citation_signal":7,"citers_with_endowment":7,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9483,"is_data_producer":true,"deposit_databanks":{"Dryad":["10.7272/Q6PG1PZ9"]},"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2021-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":490285,"name":"Mary Kagujje","orcid":"0000-0003-4818-6548","position":1,"is_corresponding":false},{"id":728011,"name":"Sarah Nyangu","orcid":null,"position":2,"is_corresponding":false},{"id":710227,"name":"Kondwelani Mateyo","orcid":"0000-0002-1498-7120","position":3,"is_corresponding":false},{"id":727422,"name":"Nsala Sanjase","orcid":"0000-0001-6103-0068","position":4,"is_corresponding":false},{"id":727423,"name":"Lophina Chilukutu","orcid":"0000-0003-4285-4293","position":5,"is_corresponding":false},{"id":371001,"name":"Ingrid Eshun‐Wilson","orcid":"0000-0002-4049-9868","position":6,"is_corresponding":false},{"id":371005,"name":"Elvin Geng","orcid":"0000-0002-0825-1424","position":7,"is_corresponding":false},{"id":58746,"name":"Diane V. Havlir","orcid":"0000-0003-0761-3136","position":8,"is_corresponding":false},{"id":490287,"name":"Monde Muyoyeta","orcid":"0000-0003-3609-5403","position":9,"is_corresponding":false},{"id":292861,"name":"Andrew D. Kerkhoff","orcid":"0000-0002-5023-6658","position":0,"is_corresponding":true}],"reference_count":32,"raw_metadata":null,"created_at":"2026-07-18T23:47:48.974996Z","pmid":"34464392","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}