Drivers of drug-resistant tuberculosis treatment initiation delay at three tertiary health facilities in Uganda: A mixed-methods study

Background Timely treatment initiation is central to drug-resistant tuberculosis (DR-TB) control. Uganda's National TB and Leprosy Programme recommends DR-TB treatment initiation within seven (Okethwangu et al., 2019 (7)) days of rifampicin-resistant TB (RR-TB) diagnosis, but the extent of delay and its drivers are poorly documented at tertiary hospitals in Uganda. This study aimed to determine the prevalence and drivers of DR-TB treatment initiation delay at three tertiary hospitals in Uganda. Methods A mixed-methods cross-sectional study conducted at Mulago National Referral Hospital (NRH), Hoima Regional Referral Hospital (RRH), and Arua RRH (December 2018–March 2019), enrolling 203 patients with Xpert MTB/RIF-confirmed RR-TB who had started DR-TB treatment. Data was from MDR-TB registers, patient charts, structured questionnaires, and 15 key informant interviews with healthcare workers. Delay was defined as treatment initiation more than seven (Okethwangu et al., 2019 (7)) days after diagnosis. Poisson regression with robust standard errors identified associated factors for delay. Results DR-TB treatment delay occurred in 65.5% (133/203) of patients overall (73.6% Mulago, 53.9% Hoima, 48.6% Arua), with median diagnosis-to-treatment time of ten (Tefera et al., 2019 (10)) days (IQR 6–20). HIV-positive status (aRR 1.48), female sex (aRR 1.31), and age ≥ 35 years (aRR 1.32) were independently associated with delay at the diagnostic level, while MDR-TB awareness was protective (aRR 0.71) and care at Mulago NRH increased delay risk (aRR 1.65). Qualitative findings pointed to delayed result notification, incomplete laboratory forms, missing baseline investigation equipment, and lack of transport funds as delay drivers. Conclusions Nearly two-thirds of DR-TB patients exceed the national seven (7)-day treatment initiation target, mainly affecting HIV-positives, women, older adults, and those at the NRH. Improved result notification, patient tracing, decentralised diagnostics, and community awareness campaigns are needed to reduce delays.