1
|
Wu Y, Zhang Y, Wang Y, Wei J, Wang W, Duan W, Tian Y, Ren M, Li Z, Wang W, Zhang T, Wu H, Huang X. Bedaquiline and Linezolid improve anti-TB treatment outcome in drug-resistant TB patients with HIV: A systematic review and meta-analysis. Pharmacol Res 2022; 182:106336. [PMID: 35779814 DOI: 10.1016/j.phrs.2022.106336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES We aimed to assess the effect of second-line anti-TB treatment and determine which drugs can achieve the greatest clinical benefit for DR-TB-HIV patients by comparing multiple chemotherapy regimens, to provide a basis for evidence-based practice. METHODS We searched three electronic databases (PubMed, Web of Science and Cochrane) for related English studies published since 2010. A random-effect model was used to estimate the pooled result for the treatment outcomes. Subgroup analysis based on possible factors, such as ART, baseline CD4 T-cell count, treatment regimens, and profiles of drug resistance, was also conducted to assess factors for favorable outcome. Outcomes were treatment success and mortality. RESULTS 38 studies, 40 cohorts with 9279 patients were included. The pooled treatment success, mortality, treatment failure, and default rates were 57.5 % (95 % CI 53.1-61.9), 21 % (95 % CI 17.8-24.6), 4.8 % (95 % CI 3.5-6.5), and 10.7 % (95 % CI 8.7-13.1), respectively, in patients with DR-TB and HIV co-infection. Subgroup analysis showed that BDQ and LZD based regimen, and ≥ 2 Group A drugs were associated with a higher treatment success rate. Besides, higher CD4 T-cell count at baseline was also correlated with higher treatment success rate, too. CONCLUSIONS Suboptimal anti-TB outcomes underlining the need to expand the application of effective drugs and better regimen in high HIV setting. BDQ and LZD based all-oral regimen and early ART could contribute to higher treatment success, particularly among XDR-TB-HIV patients. Given that all included studies were observational, our findings emphasize the need for high-quality studies to further investigate the optimal treatment regimen for DR-TB-HIV.
Collapse
Affiliation(s)
- Yaxin Wu
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Yingying Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Jiaqi Wei
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China; Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing100069, China
| | - Wenjing Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Wenshan Duan
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Yakun Tian
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Meixin Ren
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Zhen Li
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China; Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing100069, China
| | - Wen Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Tong Zhang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Hao Wu
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Xiaojie Huang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China.
| |
Collapse
|
2
|
Spies R, Schutz C, Ward A, Balfour A, Shey M, Nicol M, Burton R, Sossen B, Wilkinson R, Barr D, Meintjes G. Rifampicin resistance and mortality in patients hospitalised with HIV-associated tuberculosis. South Afr J HIV Med 2022; 23:1396. [PMID: 36299556 PMCID: PMC9575347 DOI: 10.4102/sajhivmed.v23i1.1396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/30/2022] [Indexed: 11/24/2022] Open
Abstract
Background Patients with HIV and drug-resistant tuberculosis (TB) are at high risk of death. Objectives We investigated the association between rifampicin-resistant TB (RR-TB) and mortality in a cohort of patients who were admitted to hospital at the time of TB diagnosis. Method Adults hospitalised at Khayelitsha Hospital and diagnosed with HIV-associated TB during admission, were enrolled between 2013 and 2016. Clinical, biochemical and microbiological data were prospectively collected and participants were followed up for 12 weeks. Results Participants with microbiologically confirmed TB (n = 482) were enrolled a median of two days (interquartile range [IQR]: 1-3 days) following admission. Fifty-three participants (11.0%) had RR-TB. Participants with rifampicin-susceptible TB (RS-TB) received appropriate treatment a median of one day (IQR: 1-2 days) following enrolment compared to three days (IQR: 1-9 days) in participants with RR-TB. Eight participants with RS-TB (1.9%) and six participants with RR-TB (11.3%) died prior to the initiation of appropriate treatment. Mortality at 12 weeks was 87/429 (20.3%) in the RS-TB group and 21/53 (39.6%) in the RR-TB group. RR-TB was a significant predictor of 12-week mortality (hazard ratio: 1.88; 95% confidence interval: 1.07-3.29; P = 0.03). Conclusion Mortality at 12 weeks in participants with RR-TB was high compared to participants with RS-TB. Delays in the initiation of appropriate treatment and poorer regimen efficacy are proposed as contributors to higher mortality in hospitalised patients with HIV and RR-TB.
Collapse
Affiliation(s)
- Ruan Spies
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | - Charlotte Schutz
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa) and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Amy Ward
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa) and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Avuyonke Balfour
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa) and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Muki Shey
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa) and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mark Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Rosie Burton
- Médecins sans Frontières, Cape Town, South Africa
| | - Bianca Sossen
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa) and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Robert Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa) and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,The Francis Crick Institute, London, United Kingdom.,Department of Infectious Disease, University College London, London, United Kingdom
| | - David Barr
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa) and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Graeme Meintjes
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa) and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
3
|
Edessa D, Adem F, Hagos B, Sisay M. Incidence and predictors of mortality among persons receiving second-line tuberculosis treatment in sub-Saharan Africa: A meta-analysis of 43 cohort studies. PLoS One 2021; 16:e0261149. [PMID: 34890421 PMCID: PMC8664218 DOI: 10.1371/journal.pone.0261149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/27/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Drug resistance remains from among the most feared public health threats that commonly challenges tuberculosis treatment success. Since 2010, there have been rapid evolution and advances to second-line anti-tuberculosis treatments (SLD). However, evidence on impacts of these advances on incidence of mortality are scarce and conflicting. Estimating the number of people died from any cause during the follow-up period of SLD as the incidence proportion of all-cause mortality is the most informative way of appraising the drug-resistant tuberculosis treatment outcome. We thus aimed to estimate the pooled incidence of mortality and its predictors among persons receiving the SLD in sub-Saharan Africa. METHODS We systematically identified relevant studies published between January, 2010 and March, 2020, by searching PubMed/MEDLINE, EMBASE, SCOPUS, Cochrane library, Google scholar, and Health Technology Assessment. Eligible English-language publications reported on death and/or its predictors among persons receiving SLD, but those publications that reported death among persons treated for extensively drug-resistant tuberculosis were excluded. Study features, patients' clinical characteristics, and incidence and/or predictors of mortality were extracted and pooled for effect sizes employing a random-effects model. The pooled incidence of mortality was estimated as percentage rate while risks of the individual predictors were appraised based on their independent associations with the mortality outcome. RESULTS A total of 43 studies were reviewed that revealed 31,525 patients and 4,976 deaths. The pooled incidence of mortality was 17% (95% CI: 15%-18%; I2 = 91.40; P = 0.00). The studies used varied models in identifying predictors of mortality. They found diagnoses of clinical conditions (RR: 2.36; 95% CI: 1.82-3.05); excessive substance use (RR: 2.56; 95% CI: 1.78-3.67); HIV and other comorbidities (RR: 1.96; 95% CI: 1.65-2.32); resistance to SLD (RR: 1.75; 95% CI: 1.37-2.23); and male sex (RR: 1.82; 95% CI: 1.35-2.44) as consistent predictors of the mortality. Few individual studies also reported an increased incidence of mortality among persons initiated with the SLD after a month delay (RR: 1.59; 95% CI: 0.98-2.60) and those persons with history of tuberculosis (RR: 1.21; 95% CI: 1.12-1.32). CONCLUSIONS We found about one in six persons who received SLD in sub-Saharan Africa had died in the last decade. This incidence of mortality among the drug-resistant tuberculosis patients in the sub-Saharan Africa mirrors the global average. Nevertheless, it was considerably high among the patients who had comorbidities; who were diagnosed with other clinical conditions; who had resistance to SLD; who were males and substance users. Therefore, modified measures involving shorter SLD regimens fortified with newer or repurposed drugs, differentiated care approaches, and support of substance use rehabilitation programs can help improve the treatment outcome of persons with the drug-resistant tuberculosis. TRIAL REGISTRATION NUMBER CRD42020160473; PROSPERO.
Collapse
Affiliation(s)
- Dumessa Edessa
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Fuad Adem
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Bisrat Hagos
- School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Mekonnen Sisay
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| |
Collapse
|
4
|
Foster N, Cunnama L, McCarthy K, Ramma L, Siapka M, Sinanovic E, Churchyard G, Fielding K, Grant AD, Cleary S. Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis. PLoS One 2021; 16:e0251547. [PMID: 33989317 PMCID: PMC8121360 DOI: 10.1371/journal.pone.0251547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 04/28/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In South Africa, replacing smear microscopy with Xpert-MTB/RIF (Xpert) for tuberculosis diagnosis did not reduce mortality and was cost-neutral. The unchanged mortality has been attributed to suboptimal Xpert implementation. We developed a mathematical model to explore how complementary investments may improve cost-effectiveness of the tuberculosis diagnostic algorithm. METHODS Complementary investments in the tuberculosis diagnostic pathway were compared to the status quo. Investment scenarios following an initial Xpert test included actions to reduce pre-treatment loss-to-follow-up; supporting same-day clinical diagnosis of tuberculosis after a negative result; and improving access to further tuberculosis diagnostic tests following a negative result. We estimated costs, deaths and disability-adjusted-life-years (DALYs) averted from provider and societal perspectives. Sensitivity analyses explored the mediating influence of behavioural, disease- and organisational characteristics on investment effectiveness. FINDINGS Among a cohort of symptomatic patients tested for tuberculosis, with an estimated active tuberculosis prevalence of 13%, reducing pre-treatment loss-to-follow-up from ~20% to ~0% led to a 4% (uncertainty interval [UI] 3; 4%) reduction in mortality compared to the Xpert scenario. Improving access to further tuberculosis diagnostic tests from ~4% to 90% among those with an initial negative Xpert result reduced overall mortality by 28% (UI 27; 28) at $39.70/ DALY averted. Effectiveness of investment scenarios to improve access to further diagnostic tests was dependent on a high return rate for follow-up visits. INTERPRETATION Investing in direct and indirect costs to support the TB diagnostic pathway is potentially highly cost-effective.
Collapse
Affiliation(s)
- Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kerrigan McCarthy
- Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lebogang Ramma
- Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa
| | - Mariana Siapka
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Gavin Churchyard
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aurum Institute, Johannesburg, South Africa
| | - Katherine Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
5
|
Edessa D, Sisay M, Dessie Y. Unfavorable outcomes to second-line tuberculosis therapy among HIV-infected versus HIV-uninfected patients in sub-Saharan Africa: A systematic review and meta-analysis. PLoS One 2020; 15:e0237534. [PMID: 32797110 PMCID: PMC7428180 DOI: 10.1371/journal.pone.0237534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/28/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Drug resistance is a key obstacle to the global target set to end tuberculosis by 2030. Clinical complexities in drug-resistant tuberculosis and HIV-infection co-management could worsen outcomes of second-line anti-tuberculosis drugs. A comprehensive estimate for risks of unsuccessful outcomes to second-line tuberculosis therapy in HIV-infected versus HIV-uninfected patients is mandatory to address such aspects in segments of the target set. Therefore, this meta-analysis was aimed to estimate the pooled risk ratios of unfavorable outcomes to second-line tuberculosis therapy between HIV-infected and HIV-uninfected patients in sub-Saharan Africa. METHODS We conducted a literature search from PubMed/MEDLINE, EMBASE, SCOPUS and Google Scholar. We screened the retrieved records by titles and abstracts. Finally, we assessed eligibility and quality of full-text articles for the records retained by employing appraisal checklist of the Joanna Briggs Institute. We analyzed the data extracted from the included studies by using Review Manager Software, version 5.3 and presented our findings in forest and funnel plots. Protocol for this study was registered on PROSPERO (ID: CRD42020160473). RESULTS A total of 19 studies with 1,766 from 4,481 HIV-infected and 1,164 from 3,820 HIV-uninfected patients had unfavorable outcomes. The risk ratios we estimated between HIV-infected and HIV-uninfected drug-resistant tuberculosis patients were 1.18 (95% CI: 1.07-1.30; I2 = 48%; P = 0.01) for the overall unfavorable outcome; 1.50 (95% CI: 1.30-1.74) for death; 0.66 (95% CI: 0.38-1.13) for treatment failure; and 0.82 (95% CI: 0.74-0.92) for loss from treatment. Variable increased risks of unfavorable outcomes estimated for subgroups with significance in mixed-age patients (RR: 1.22; 95% CI: 1.10-1.36) and eastern region of sub-Saharan Africa (RR: 1.47; 95% CI: 1.23-1.75). CONCLUSIONS We found a higher risk of unfavorable treatment outcome in drug-resistant tuberculosis patients with death highly worsening in HIV-infected than in those HIV-uninfected patients. The risks for the unfavorable outcomes were significantly higher in mixed-age patients and in the eastern region of sub-Saharan Africa. Therefore, special strategies that reduce the risks of death should be discovered and implemented for HIV and drug-resistant tuberculosis co-infected patients on second-line tuberculosis therapy with optimal integration of the two programs in the eastern region of sub-Saharan Africa.
Collapse
Affiliation(s)
- Dumessa Edessa
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Oromia, Ethiopia
| | - Mekonnen Sisay
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Oromia, Ethiopia
| | - Yadeta Dessie
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Oromia, Ethiopia
| |
Collapse
|
6
|
Law S, Daftary A, O'Donnell M, Padayatchi N, Calzavara L, Menzies D. Interventions to improve retention-in-care and treatment adherence among patients with drug-resistant tuberculosis: a systematic review. Eur Respir J 2019; 53:13993003.01030-2018. [PMID: 30309972 DOI: 10.1183/13993003.01030-2018] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/20/2018] [Indexed: 11/05/2022]
Abstract
The global loss to follow-up (LTFU) rate among drug-resistant tuberculosis (DR-TB) patients remains high at 15%. We conducted a systematic review to explore interventions to reduce LTFU during DR-TB treatment.We searched for studies published between January 2000 and December 2017 that provided any form of psychosocial or material support for patients with DR-TB. We estimated point estimates and 95% confidence intervals of the proportion LTFU. We performed subgroup analyses and pooled estimates using an exact binomial likelihood approach.We included 35 DR-TB cohorts from 25 studies, with a pooled proportion LTFU of 17 (12-23)%. Cohorts that received any form of psychosocial or material support had lower LTFU rates than those that received standard care. Psychosocial support throughout treatment, via counselling sessions or home visits, was associated with lower LTFU rates compared to when support was provided through a limited number of visits or not at all.Our review suggests that psychosocial support should be provided throughout DR-TB treatment in order to reduce treatment LTFU. Future studies should explore the potential of providing self-administered therapy complemented with psychosocial support during the continuation phase.
Collapse
Affiliation(s)
- Stephanie Law
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Amrita Daftary
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,McGill International TB Centre, McGill University, Montreal, QC, Canada.,CAPRISA-MRC TB-HIV Pathogenesis and Treatment Unit, Durban, South Africa
| | - Max O'Donnell
- CAPRISA-MRC TB-HIV Pathogenesis and Treatment Unit, Durban, South Africa.,Division of Pulmonary, Allergy and Critical Care Medicine, and Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Nesri Padayatchi
- CAPRISA-MRC TB-HIV Pathogenesis and Treatment Unit, Durban, South Africa
| | - Liviana Calzavara
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Dick Menzies
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,McGill International TB Centre, McGill University, Montreal, QC, Canada
| |
Collapse
|
7
|
Evans D, Sineke T, Schnippel K, Berhanu R, Govathson C, Black A, Long L, Rosen S. Impact of Xpert MTB/RIF and decentralized care on linkage to care and drug-resistant tuberculosis treatment outcomes in Johannesburg, South Africa. BMC Health Serv Res 2018; 18:973. [PMID: 30558670 PMCID: PMC6296148 DOI: 10.1186/s12913-018-3762-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 11/23/2018] [Indexed: 11/16/2022] Open
Abstract
Background In 2011, South Africa improved its ability to test for rifampicin-resistant TB (RR-TB) by introducing GeneXpert MTB/RIF. At the same time, the South African National TB program adopted a policy decentralized, outpatient treatment for drug resistant (DR-) TB. We aim to analyze the impact of these changes on linkage to care and DR-TB treatment outcomes. Methods We retrospectively matched adult patients diagnosed with laboratory-confirmed RR-TB in Johannesburg from 07/2011–06/2012 (early cohort) and 07/2013–06/2014 (late cohort) with records of patients initiating DR-TB treatment at one of the city’s four public sector treatment sites. We determine the proportion of persons diagnosed with RR-TB who initiated DR-TB treatment and report time to treatment initiation (TTI) before and after the implementation of Xpert MTB/RIF roll-out in Johannesburg, South Africa. We conducted a sub-analysis among those who initiated DR-TB treatment at the decentralized outpatient DR-TB centers to determine if delays in treatment initiation have a subsequent impact on treatment outcomes. Results Five hundred ninety four patients were enrolled in the early cohort versus 713 in the late cohort. 53.8 and 36.8% of patients were diagnosed with multi-drug resistant TB in the early and late cohorts, respectively. The proportion of RR-TB confirmed cases diagnosed by Xpert MTB/RIF increased from 43.4 to 60.5% between the early and late cohorts, respectively. The proportion who initiated treatment increased from 43.1% (n = 256) to 60.3% (n = 430) in the late cohort. Pre-treatment mortality during the early and the late cohort reduced significantly from 17.5 to 5.8% while lost to follow-up remained high. Although TTI reduced by a median of 19 days, from 33 days (IQR 12–52) in the early cohort to 14 days (IQR 7–31) in the late cohort, this did not translate to improved treatment outcomes and we found no difference in terms of treatment success or on-treatment mortality for those that initiated without delay vs. those that deferred initiation. Conclusion Pre-treatment mortality reduced significantly during late Xpert MTB/RIF coverage but there was no significant difference after treatment was initiated. Despite improvements there is still a significant diagnosis and treatment gap for patients diagnosed with RR-TB and improving treatment outcomes remains critical. Electronic supplementary material The online version of this article (10.1186/s12913-018-3762-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathryn Schnippel
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rebecca Berhanu
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Caroline Govathson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Black
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| |
Collapse
|
8
|
Hirasen K, Berhanu R, Evans D, Rosen S, Sanne I, Long L. High rates of death and loss to follow-up by 12 months of rifampicin resistant TB treatment in South Africa. PLoS One 2018; 13:e0205463. [PMID: 30300403 PMCID: PMC6177165 DOI: 10.1371/journal.pone.0205463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/25/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Treatment success rates of rifampicin resistant (RR)/multi-drug resistant (MDR) tuberculosis (TB) in South Africa range from 43–48%, falling short of the World Health Organization’s target of ≥75%. We present rates and assess predictors of attrition by 12 months on treatment. Methods Prospective observational cohort analysis of adults (≥18 years) initiating RR/MDR-TB treatment from 01 March 2013 to 30 September 2016. Attrition was defined as a combination of death and loss to follow-up (LTFU; treatment interruption ≥2 months) by 12 months on treatment. Predictors of attrition were identified using Cox Proportional Hazards models to estimate crude (HR) and adjusted hazard ratios (aHR) with corresponding 95% confidence intervals. Results By 12 months on treatment, 75/240 (31.3%) patients had either died (37/240; 15.4%) or been LTFU (38/240; 15.8%). Patients with moderate/severe anaemia (aHR: 2.10; 95% CI 1.00–4.39), and those who were smear positive at baseline (aHR: 2.04; 95% CI 1.01–4.12) were significantly more likely to die or be lost from care. Conclusion At this outpatient DR-TB treatment site, there was a high rate of attrition halfway through the standard treatment course at 12 months of 31%. High rates of attrition by 12 months on treatment may continue during the second-half of therapy.
Collapse
Affiliation(s)
- Kamban Hirasen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rebecca Berhanu
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of infectious diseases, University of North Carolina, Chapel Hill, United States of America
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, School of Public Health, Boston University, Boston, MA, United States of America
| | - Ian Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Right to care, Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, School of Public Health, Boston University, Boston, MA, United States of America
| |
Collapse
|
9
|
Mohr E, Snyman L, Mbakaz Z, Caldwell J, DeAzevedo V, Kock Y, Trivino Duran L, Venables E. "Life continues": Patient, health care and community care workers perspectives on self-administered treatment for rifampicin-resistant tuberculosis in Khayelitsha, South Africa. PLoS One 2018; 13:e0203888. [PMID: 30216368 PMCID: PMC6138394 DOI: 10.1371/journal.pone.0203888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/29/2018] [Indexed: 11/19/2022] Open
Abstract
Background Self-administered treatment (SAT), a differentiated model of care for rifampicin-resistant tuberculosis (RR-TB), might address adherence challenges faced by patients and health care systems. This study explored patient, health-care worker (HCW) and community care worker (CCW) perspectives on a SAT pilot programme in South Africa, in which patients were given medication to take at home with the optional support of a CCW. Methods We conducted a mixed-methods study from July 2016-June 2017. The quantitative component included semi-structured questionnaires with patients, HCWs and CCWs; the qualitative component involved in-depth interviews with patients enrolled in the pilot programme. Interviews were conducted in isiXhosa, translated, transcribed and manually coded. Results Overall, 27 patients, 12 HCWs and 44 CCWs were enrolled in the quantitative component; nine patients were also interviewed. Of the 27 patients who completed semi-structured questionnaires, 22 were HIV-infected and 17 received a monthly supply of RR TB treatment. Most HCWs and CCWs (10 and 32, respectively) understood the pilot programme; approximately half (n = 14) of the patients could not correctly describe the pilot programme. Overall, 11 and 41 HCWs and CCWs reported that the pilot programme promoted treatment adherence. Additionally, 11 HCWs reported that the pilot programme relieved pressure on the clinic. Key qualitative findings highlighted the importance of a support person and how the flexibility of SAT enabled integration of treatment into their daily routines and reduced time spent in clinics. The pilot programme was also perceived to allow patients more autonomy and made it easier for them to manage side-effects. Conclusion The SAT pilot programme was acceptable from the perspective of patients, HCWs and CCWs and should be considered as a differentiated model of care for RR-TB, particularly in settings with high burdens of HIV, in order to ease management of treatment for patients and health-care providers.
Collapse
Affiliation(s)
- Erika Mohr
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
- * E-mail:
| | - Leigh Snyman
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - Zodwa Mbakaz
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - Judy Caldwell
- City of Cape Town Health Department, Cape Town, South Africa
| | | | - Yulene Kock
- Provincial Government of the Western Cape Department of Health, Cape Town, South Africa
| | | | - Emilie Venables
- Southern Africa Medical Unit, Médecins Sans Frontières (MSF), Cape Town, South Africa
- University of Cape Town (UCT), Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, Cape Town, South Africa
| |
Collapse
|
10
|
Brust JCM, Shah NS, Mlisana K, Moodley P, Allana S, Campbell A, Johnson BA, Master I, Mthiyane T, Lachman S, Larkan LM, Ning Y, Malik A, Smith JP, Gandhi NR. Improved Survival and Cure Rates With Concurrent Treatment for Multidrug-Resistant Tuberculosis-Human Immunodeficiency Virus Coinfection in South Africa. Clin Infect Dis 2018; 66:1246-1253. [PMID: 29293906 PMCID: PMC5888963 DOI: 10.1093/cid/cix1125] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 12/22/2017] [Indexed: 11/12/2022] Open
Abstract
Background Mortality in multidrug-resistant (MDR) tuberculosis-human immunodeficiency virus (HIV) coinfection has historically been high, but most studies predated the availability of antiretroviral therapy (ART). We prospectively compared survival and treatment outcomes in MDR tuberculosis-HIV-coinfected patients on ART to those in patients with MDR tuberculosis alone. Methods This observational study enrolled culture-confirmed MDR tuberculosis patients with and without HIV in South Africa between 2011 and 2013. Participants received standardized MDR tuberculosis and HIV regimens and were followed monthly for treatment response, adverse events, and adherence. The primary outcome was survival. Results Among 206 participants, 150 were HIV infected, 131 (64%) were female, and the median age was 33 years (interquartile range [IQR], 26-41). Of the 191 participants with a final MDR tuberculosis outcome, 130 (73%) were cured or completed treatment, which did not differ by HIV status (P = .50). After 2 years, CD4 count increased a median of 140 cells/mm3 (P = .005), and 64% had an undetectable HIV viral load. HIV-infected and HIV-uninfected participants had high rates of survival (86% and 94%, respectively; P = .34). The strongest risk factor for mortality was having a CD4 count ≤100 cells/mm3 (adjusted hazards ratio, 15.6; 95% confidence interval, 4.4-55.6). Conclusions Survival and treatment outcomes among MDR tuberculosis-HIV individuals receiving concurrent ART approached those of HIV-uninfected patients. The greatest risk of death was among HIV-infected individuals with CD4 counts ≤100 cells/mm3. These findings provide critical evidence to support concurrent treatment of MDR tuberculosis and HIV.
Collapse
Affiliation(s)
- James C M Brust
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - N Sarita Shah
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Koleka Mlisana
- University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Services, Durban, South Africa
| | - Pravi Moodley
- University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Services, Durban, South Africa
| | - Salim Allana
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Angela Campbell
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | | | | | - Yuming Ning
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Amyn Malik
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jonathan P Smith
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Neel R Gandhi
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory School of Medicine, Emory University, Atlanta, Georgia
| |
Collapse
|
11
|
Optimal Management of Drug-Resistant Tuberculosis and Human Immunodeficiency Virus: an Update. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0145-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
12
|
Mohr E, Daniels J, Beko B, Isaakidis P, Cox V, Steele SJ, Muller O, Snyman L, De Azevedo V, Shroufi A, Trivino Duran L, Hughes J. DOT or SAT for Rifampicin-resistant tuberculosis? A non-randomized comparison in a high HIV-prevalence setting. PLoS One 2017; 12:e0178054. [PMID: 28542441 PMCID: PMC5436852 DOI: 10.1371/journal.pone.0178054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/08/2017] [Indexed: 11/19/2022] Open
Abstract
Background Daily directly-observed therapy (DOT) is recommended for rifampicin-resistant tuberculosis (RR-TB) patients throughout treatment. We assessed the impact of self-administered treatment (SAT) in a South African township with high rates of RR-TB and HIV. Methods Community-supported SAT for patients who completed the intensive phase was piloted in five primary care clinics in Khayelitsha. We compared final treatment outcomes among RR-TB patients initiating treatment before (standard-of-care (SOC)-cohort, January 2010-July 2013) and after the implementation of the pilot (SAT-cohort, January 2012-December 2014). All patients with outcomes before January 1, 2017 were considered in the analysis of outcomes. Results One-hundred-eighteen patients in the SOC-cohort and 174 patients in the SAT-cohort had final RR-TB treatment outcomes; 70% and 73% were HIV-co-infected, respectively. The proportion of patients with a final outcome of loss to follow-up (LTFU) did not differ whether treated in the SOC (25/118, 21.2%) or SAT-cohort (31/174, 17.8%) (P = 0.47). There were no significant differences in the time to 24-month LTFU among HIV-infected and uninfected patients (HR 0.90, 95% CI: 0.51–1.6, P = 0.71), or among patients enrolled in the SOC-cohort versus the SAT-cohort (HR 0.83, 95% CI: 0.49–1.4, P = 0.50) who received at least 6-months of RR-TB treatment. Conclusion The introduction of SAT during the continuation phase of RR-TB treatment does not adversely affect final RR-TB treatment outcomes in a high TB and HIV-burden setting. This differentiated, patient-centred model of care could be considered in RR-TB programmes to decrease the burden of DOT on patients and health facilities.
Collapse
Affiliation(s)
- Erika Mohr
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
- * E-mail:
| | - Johnny Daniels
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - Busisiwe Beko
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - Petros Isaakidis
- Médecins Sans Frontières (MSF), South African Medical Unit, Cape Town, South Africa
| | - Vivian Cox
- University of Cape Town (UCT), Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Cape Town, South Africa
| | | | - Odelia Muller
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - Leigh Snyman
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | | | - Amir Shroufi
- Médecins Sans Frontières (MSF), Cape Town, South Africa
| | | | | |
Collapse
|
13
|
Berhanu R, Schnippel K, Mohr E, Hirasen K, Evans D, Rosen S, Sanne I. Early Outcomes Of Decentralized Care for Rifampicin-Resistant Tuberculosis in Johannesburg, South Africa: An Observational Cohort Study. PLoS One 2016; 11:e0164974. [PMID: 27812140 PMCID: PMC5094796 DOI: 10.1371/journal.pone.0164974] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/04/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We describe baseline characteristics, time to treatment initiation and interim patient outcomes at a decentralized, outpatient treatment site for rifampicin-resistant TB (RR-TB). METHODS Prospective observational cohort study of RR-TB patients from March 2013 until December 2014. Study subjects were followed until completion of the intensive phase of treatment (6 months), transfer out, or a final outcome (loss from treatment (LFT) or death). RESULTS 214 patients with RR-TB were enrolled in the study. Xpert MTB/RIF was the diagnostic test of rifampicin resistance for 87% (n = 186), followed by direct PCR on AFB positive specimen in 14 (7%) and indirect PCR on cultured isolate in 5 (2%). Median time between sputum testing and treatment initiation was 10 days (IQR 6-21). Interim outcomes were available in 148 patients of whom 78% (n = 115) were still on treatment, 9% (n = 13) had died, and 14% (n = 20) were LFT. Amongst 131 patients with culture positive pulmonary TB, 85 (64.9%) were culture negative at 6 months, 12 were still sputum culture positive (9.2%) and 34 had no culture documented or contaminated culture (26%). Patients who initiated as outpatients within 1 week of sputum collection for diagnosis of RR-TB had a significantly lower incidence of LFT (IRR 0.30, 95% CI: 0.09-0.98). HIV co-infection occurred in 178 patients (83%) with a median CD4 count 88 cells/ml3 (IQR 27-218). CONCLUSIONS Access to decentralized treatment coupled with the rapid diagnosis of RR-TB has resulted in short time to treatment initiation. Despite the lack of treatment delays, early treatment outcomes remain poor with high rates of death and loss from care.
Collapse
Affiliation(s)
- Rebecca Berhanu
- Right to Care, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathryn Schnippel
- Right to Care, Johannesburg, South Africa
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Erika Mohr
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Kamban Hirasen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, MA, United States of America
| | - Ian Sanne
- Right to Care, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
14
|
Harris RC, Grandjean L, Martin LJ, Miller AJP, Nkang JEN, Allen V, Khan MS, Fielding K, Moore DAJ. The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review. BMC Infect Dis 2016; 16:193. [PMID: 27142682 PMCID: PMC4855810 DOI: 10.1186/s12879-016-1524-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 04/22/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Globally it is estimated that 480 000 people developed multidrug-resistant tuberculosis (MDR-TB) in 2014 and 190 000 people died from the disease. Successful treatment outcomes are achieved in only 50 % of patients with MDR-TB, compared to 86 % for drug susceptible disease. It is widely held that delay in time to initiation of treatment for MDR-TB is an important predictor of treatment outcome. The objective of this review was to assess the existing evidence on the outcomes of multidrug- and extensively drug-resistant tuberculosis patients treated early (≤4 weeks) versus late (>4 weeks) after diagnosis of drug resistance. METHODS Eight sources providing access to 17 globally representative electronic health care databases, indexes, sources of evidence-based reviews and grey literature were searched using terms incorporating time to treatment and MDR-TB. Two-stage sifting in duplicate was employed to assess studies against pre-specified inclusion and exclusion criteria. Only those articles reporting WHO-defined treatment outcomes were considered for inclusion. Articles reporting on fewer than 10 patients, published before 1990, or without a comparison of outcomes in patient groups experiencing different delays to treatment initiation were excluded. RESULTS The initial search yielded 1978 references, of which 1475 unique references remained after removal of duplicates and 28 articles published pre-1990. After title and abstract sifting, 64 papers underwent full text review. None of these articles fulfilled the criteria for inclusion in the review. CONCLUSIONS Whilst there is an inherent logic in the theory that treatment delay will lead to poorer treatment outcomes, no published evidence was identified in this systematic review to support this hypothesis. Reports of programmatic changes leading to reductions in treatment delay exist in the literature, but attribution of differences in outcomes specifically to treatment delay is confounded by other contemporaneous changes. Further primary research on this question is not considered a high priority use of limited resources, though where data are available, improved reporting of outcomes by time to treatment should be encouraged.
Collapse
Affiliation(s)
- Rebecca C Harris
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Louis Grandjean
- Department of Infection, Immunology and Rheumatology, University College London, Institute of Child Health, Guilford Street, London, WC1E 6BT, UK
| | - Laura J Martin
- Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK
| | - Alexander J P Miller
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Joseph-Egre N Nkang
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Victoria Allen
- Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - Mishal S Khan
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, 119077, Singapore
| | - Katherine Fielding
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - David A J Moore
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| |
Collapse
|
15
|
Daniels JF, Khogali M, Mohr E, Cox V, Moyo S, Edginton M, Hinderaker SG, Meintjes G, Hughes J, De Azevedo V, van Cutsem G, Cox HS. Time to ART Initiation among Patients Treated for Rifampicin-Resistant Tuberculosis in Khayelitsha, South Africa: Impact on Mortality and Treatment Success. PLoS One 2015; 10:e0142873. [PMID: 26555134 PMCID: PMC4640533 DOI: 10.1371/journal.pone.0142873] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/27/2015] [Indexed: 11/18/2022] Open
Abstract
SETTING Khayelitsha, South Africa, with high burdens of rifampicin-resistant tuberculosis (RR-TB) and HIV co-infection. OBJECTIVE To describe time to antiretroviral treatment (ART) initiation among HIV-infected RR-TB patients initiating RR-TB treatment and to assess the association between time to ART initiation and treatment outcomes. DESIGN A retrospective cohort study of patients with RR-TB and HIV co-infection not on ART at RR-TB treatment initiation. RESULTS Of the 696 RR-TB and HIV-infected patients initiated on RR-TB treatment between 2009 and 2013, 303 (44%) were not on ART when RR-TB treatment was initiated. The median CD4 cell count was 126 cells/mm3. Overall 257 (85%) patients started ART during RR-TB treatment, 33 (11%) within 2 weeks, 152 (50%) between 2-8 weeks and 72 (24%) after 8 weeks. Of the 46 (15%) who never started ART, 10 (21%) died or stopped RR-TB treatment within 4 weeks and 16 (37%) had at least 4 months of RR-TB treatment. Treatment success and mortality during treatment did not vary by time to ART initiation: treatment success was 41%, 43%, and 50% among patients who started ART within 2 weeks, between 2-8 weeks, and after 8 weeks (p = 0.62), while mortality was 21%, 13% and 15% respectively (p = 0.57). Mortality was associated with never receiving ART (adjusted hazard ratio (aHR) 6.0, CI 2.1-18.1), CD4 count ≤100 (aHR 2.1, CI 1.0-4.5), and multidrug-resistant tuberculosis (MDR-TB) with second-line resistance (aHR 2.5, CI 1.1-5.4). CONCLUSIONS Despite wide variation in time to ART initiation among RR-TB patients, no differences in mortality or treatment success were observed. However, a significant proportion of patients did not initiate ART despite receiving >4 months of RR-TB treatment. Programmatic priorities should focus on ensuring all patients with RR-TB/HIV co-infection initiate ART regardless of CD4 count, with special attention for patients with CD4 counts ≤ 100 to initiate ART as soon as possible after RR-TB treatment initiation.
Collapse
Affiliation(s)
| | | | - Erika Mohr
- Médecins sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Vivian Cox
- Médecins sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Sizulu Moyo
- Médecins sans Frontières, Khayelitsha, Cape Town, South Africa
- Human Sciences Research Council, HIV/AIDS, STIs and TB programme, Cape Town, South Africa
| | - Mary Edginton
- International Union against TB and Lung Disease, Paris, France
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Hughes
- Médecins sans Frontières, Khayelitsha, Cape Town, South Africa
| | | | - Gilles van Cutsem
- Médecins sans Frontières, Khayelitsha, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Helen Suzanne Cox
- Division of Medical Microbiology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|