Early outcomes of MDR-TB treatment in a high HIV-prevalence setting in Southern Africa

Abstract

Background: Little is known about treatment of multidrug-resistant tuberculosis (MDR-TB) in high HIV-prevalence settings such as sub-Saharan Africa.

Methodology/principal findings: We did a retrospective analysis of early outcomes of the first cohort of patients registered in the Lesotho national MDR-TB program between July 21, 2007 and April 21, 2008. Seventy-six patients were included for analysis. Patient follow-up ended when an outcome was recorded, or on October 21, 2008 for those still on treatment. Fifty-six patients (74%) were infected with HIV; the median CD4 cell count was 184 cells/microl (range 5-824 cells/microl). By the end of the follow-up period, study patients had been followed for a median of 252 days (range 12-451 days). Twenty-two patients (29%) had died, and 52 patients (68%) were alive and in treatment. In patients who did not die, culture conversion was documented in 52/54 patients (96%). One patient had defaulted, and one patient had transferred out. Death occurred after a median of 66 days in treatment (range 12-374 days).

Conclusions/significance: In a region where clinicians and program managers are increasingly confronted by drug-resistant tuberculosis, this report provides sobering evidence of the difficulty of MDR-TB treatment in high HIV-prevalence settings. In Lesotho, an innovative community-based treatment model that involved social and nutritional support, twice-daily directly observed treatment and early empiric use of second-line TB drugs was successful in reducing mortality of MDR-TB patients. Further research is urgently needed to improve MDR-TB treatment outcomes in high HIV-prevalence settings.

Figure 1. Major adverse effects and clinical complications during MDR-TB treatment.

Adverse effects and clinical complications were defined as in Table 2. Percentages were calculated out of a total of 76 patients.

Figure 2. Time to death during MDR-TB treatment by HIV status.

This figure shows Kaplan-Meier probabilities of survival in HIV-negative (solid line) and HIV-positive (dotted line) patients. Survival is measured in days after starting MDR-TB treatment. Crosses indicate patients who did not die by the end of the follow-up period.