This study sought to understand the perception of health professionals about MDR-TB, their strategies to ensure adherence to treatment and challenges in the context of the pandemic of COVID-19, in a priority municipality for disease control in the state of São Paulo, Brazil. The results found signal the issues that permeate SHD, and also strategic mechanisms adopted to achieve adherence, having COVID-19 as an important stressor.
It is important to highlight that the professionals expressed great concern at the meeting between MDR-TB and COVID-19, since the situation of the pandemic has interfered in all the dynamics of patients diagnosed with MDR-TB, and if the treatment is interrupted, there are chances of dissemination of the disease. MDR-TB, which can make it a difficult to control situation, weakening the response capacity to confront MDR-TB.
Regarding the approach of professionals to understand MDR-TB, it must be said that they are extremely important actors because they have a broader view of the problems and difficulties that are encountered in carrying out the monitoring of patients with MDR-TB, however many times these they are powerless in the face of the need to solve problems with their patients.
During the interviews, many professionals reported that the fact that the patient has progressed to MDR-TB is often due to the social class in which he / she is inserted, stating that low-income population groups are more likely to fall ill. Knowing that poverty is one of the most important determinants of TB, it can also worsen the health condition of individuals [26]. Thus, TB and poverty maintain a dependency relationship, as poverty can be associated with precarious health conditions, as these can produce poverty, by reducing opportunities for work and subsistence [27].
In addition, we have a lack of adherence to treatment, according to reports, the interviewees link non-adherence to the fact that these patients are on the street, are drug users and, consequently, poverty as a direct influence in these cases, leading to abandonment. According to [28], adherence to treatment is a multidimensional phenomenon, associated with factors such as the conception of the disease, the treatment itself, the relationship between the health system and professionals.
In order to minimize the dropouts, adherence strategies in the treatment of MDR-TB were presented by most of the interviewees, an example of which are the benefits that were offered to this public. The social protection that covers TB patients can provide a means for them to reduce treatment defaults, especially for the poorest [26]. A meta-analysis carried out with data from nine randomized clinical trials involving 1,687 participants showed that social protection strategies improve access to health care and, consequently, adherence to TB treatment [26]. For these interviewed professionals, this question was seen as something positive to maintain regular follow-up, as these actions enable access, the bond that they often use as a subsidy for the adequate treatment.
However, a weakness brought to the study is that regular monitoring of patients with MDR-TB has been hindered by the situation of COVID-19, given that many professionals had to decrease home visits due to the lack of professionals and subsidies. The interpersonal relationship that takes place between patients and health professionals in the performance of DOT, is of paramount importance for the motivation and follow-up of the treatment, assessment of the risk of abandonment, and also for the management of side effects, however, interrupting this process can affect the continuity of patients.
Thus, new conformations of the health system and care practices are being considered in the context of the pandemic, with emphasis on the implementation of Web-DOT, which enables remote monitoring of TB patients and guarantees this adherence [29] as well as mobilizing family volunteers to supervise these patients under treatment.
The study also showed a great concern of the professionals with the worsening of the patient's health situation, given that they are already with MDR-TB and if they also contracted COVID-19, they would have great chances of more severe conditions, due to the condition of the lung weakened by MDR-TB. In addition, no patient was reported under this condition, but a great effort by the professionals to prevent the situation.
In the literature, it is observed that therapeutic discontinuities also result from the form of organization of health services, which sometimes has an incompatible functioning agenda, from a patient who is working in formality and or informality [30], the requirement for the patient to visit the health center, sometimes very far from home, without any financial support from the health system which requires an approach also with this actor.
The elimination of TB runs through the question of understanding the determinants of MDR-TB in the light of different perspectives, including that of professionals who are on the front line of care. The issue of MDR-TB was already a challenge in the country, due to the low percentages of adherence, and it can intensify with the pandemic, however the study showed a commitment on the part of professionals to face the situation, to achieve equity in care.
The limitations of the study refer to the scope of the study, with a qualitative orientation, thus preventing generalizations for the population from which the study participants come, and in addition, due to the approach used online, which may have prevented researchers from being able to capture other forms of communication, non-verbal. It would be of great importance for future studies to include patients diagnosed with MDR-TB in order to carry out an investigation on both sides of the therapeutic relationships. However, the study brought relevant points for qualification and development of services, being one of the first, which has been working with MDR-TB in the context of the pandemic.