Table 1 Barriers and enablers in the pathway to early MDR-TB diagnosis and treatment initiation

Symptom recognition

•Symptom recognition based on history of previous TB

•Failure to recognise TB symptoms

•Minimisation or denial of symptoms

•Social contact with TB/MDR-TB patients

•Lack of awareness that TB can recur

•Awareness of increased risk of TB amongst HIV-infected patients

•Incorrectly ascribing symptoms to HIV or other medical condition

Accessing health-care

•Perceptions of good quality service

•Negative perceptions of the public sector (over-burdened; long waiting times; negative staff attitudes; lack of privacy)

•Convenience of free, accessible local services.

•Familiarity with service

•Family support

•Fear of an HIV diagnosis

•Responsiveness of provider at first health contact

•Social construct of “being a man”, not admitting illness (seen as weakness)

MDR-TB Testing

•Attendance at facilities geared towards TB (i.e. offering both TB diagnosis and treatment)

•Entry point to care through the private sector

•Availability of Xpert MTB/RIF

•Accessing facilities providing TB diagnostic but not treatment services.

•Screening of all presumptive TB cases for drug resistance

•Health providers failure to test for TB / MDR-TB at initial health contact

•Patient’s agency in specifically requesting TB screening services that were not offered

•Health providers’ failure to follow diagnostic algorithms

•Patient’s agency in pursuing diagnostic processes after initial negative tests

•Interruptions to the diagnostic process due to dissatisfaction with the service, work and family commitments

•Lack of money for transport to return to facility

•Insensitive tests that fail to diagnose TB

•Patients diagnosed clinically or on chest x-ray and started on 1^st-line TB treatment

•Failure to respond early to clinical deterioration for patients on 1^st-line TB treatment

Initiating MDR-TB Treatment

•Health provider scheduling early return visits for MDR-TB test results

•Patients failure to return for follow-up appointments

•Patients returning for scheduled appointments

•Delays in recalling patients

•Availability of decentralised MDR-TB treatment

•Results not being available at follow-up appointments

•Perceptions that staff cared about their patient’s well-being

•Family commitments preventing a return to facilities

•Cultural beliefs and seeking traditional healthcare (often in another province)