1. TB physicians’ perspectives on barriers to deliver brief counseling interventions (BCI) within routine tuberculosis services: A qualitative study on a successful intervention for sustainability in post-research phase (Tomsk, Russia) Viktoriya Livchits Alexandra Solovyova Sonya Shin 46th Union World Conference on Lung Health Cape Town, 2015 Symposium 31. High burden, neglected patients: addressing the intersection of tuberculosis and mental disorders

2. Tomsk Oblast Population: 1,043 million Area: 314 391 km 2 Incidence of TB is 66/100,000 (2014) Incidence of Alcoholism is 50/100,000 (2014)

3. The initial study IMPACT (Integrated Management of Physician- delivered Alcohol Care for Tuberculosis patients), 2007 – 2011. Study Design: Randomized controlled trial. Study population: The majority of TB patients had a diagnosis of an AUD (63.0%); 27.6% reported nearly daily drinking and consumed a median of 16 standard drinks per day.

4. 31. High burden, neglected patients: Alcohol interventions were delivered monthly by TB physicians as part of a 6-month directly observed therapy, short-course (“DOTS”) protocol for TB treatment. All patients in research were randomized into four groups with different interventions: 1.Brief Counseling Interventions (BCI) 2.Naltrexone (NTX) 3.BCI + NTX 4.Treatment as usual adjunct to DOTS (TAU)

5. Findings There was no significant difference in TB outcomes between Naltrexone and no-Naltrexone groups or between BCI and no-BCI groups. Mean abstinent days, heavy drinking days, and average consumption per drinking day and per heavy drinking day (secondary outcomes) did not differ significantly by treatment arm. Among individuals with prior attempts to quit drinking (n=111), Naltrexone use was associated with an increased likelihood of a favorable TB outcome (92.3% versus 75.9%, P=0.02), but had no correlation with other alcohol and TB outcomes.

6. If it hasn’t worked, why to continue? Most practitioners reported definite enhancements in knowledge or confidence in discussing alcohol issues with clients following the training. Delivering these types of services will require to move toward a team model, in which nurses, social workers, or other clinicians (ex. psychologists) work more closely with physicians and administer behavioral interventions.

7. Post – research interview Audio-taped individual interviews using semi- structured questionnaires Four TB practitioners from Tomsk TB Services (out of six who had participated in the RCT) Interviews were transcribed, coded with a standardized framework, and analyzed to identify emergent domains Used domain analysis to describe the TB doctors’ perceptions of the multi-level factors that influence BCI practice in post-RCT phase and illustrate current situation in providing care to TB patients with alcohol use disorders (AUD)

8. What we have found All participants discontinued BCI at some point and the motivational interview (MI) skills were not sustained after the completion of the research. Key barriers providing BCI systematically, including: high workload, low staff motivation, lack of booster trainings, and lack of interest from the administration. Physicians have expressed concern that the study do not reflect the realities of Practice.

9. What have the interviews illustrated The MI approach is significantly different from traditional treatment care provided in the TB settings -- “expert-driven, practitioner-centered” model. Physicians do not have enough time to address patients’ existing conditions and to implement all the recommendations, so they must prioritize. The medical system is geared toward treating main illness and facilitating the provision of interventions for harmful alcohol use will require major shifts in the way care is delivered.

10. Doctors’ suggestions Assigning a counseling coordinator Setting up each patient’s management map at the hospital entry point Monitoring accomplishments Coaching new medical staff Establish recognition and incentives for good counseling practices Provide intensive booster series of trainings 31. High burden, neglected patients:

11. Current regional programs Session 2 Within first week Video Modules (Tuberculosis: infection, symptoms and diagnosis, treatment, medication, and side effects) and a survey with discussions – Group/Individual Session 3 Second week Building commitment to treatment adherence – Group/Individual Session 4 In 1 month Assessment of adherence and progress of treatment -- Individual Session 1 First 2 days after diagnosis Emotional support and motivation (motivational interview skills) – Individual

12. THANK YOU! “Sometimes we are not as good as we should be in our capacity to understand feelings and thoughts of our patients. So, maybe part of our education should be training in empathy…” Quotes from one of the Interview