BACKGROUND Extensively drug-resistant tuberculosis has been reported in 45 countries, including countries with limited resources and a high burden of tuberculosis. We describe the management of extensively drug-resistant tuberculosis and treatment outcomes among patients who were referred for individualized outpatient therapy in Peru. METHODS A total of 810 patients were referred for free individualized therapy, including drug treatment, resective surgery, adverse-event management, and nutritional and psychosocial support. We tested isolates from 651 patients for extensively drug-resistant tuberculosis and developed regimens that included five or more drugs to which the infecting isolate was not resistant. RESULTS Of the 651 patients tested, 48 (7.4%) had extensively drug-resistant tuberculosis; the remaining 603 patients had multidrug-resistant tuberculosis. The patients with extensively drug-resistant tuberculosis had undergone more treatment than the other patients (mean [±SD] number of regimens, 4.2±1.9 vs. 3.2±1.6; P<0.001) and had isolates that were resistant to more drugs (number of drugs, 8.4±1.1 vs. 5.3±1.5; P<0.001). None of the patients with extensively drug-resistant tuberculosis were coinfected with the human immunodeficiency virus (HIV). Patients with extensively drug-resistant tuberculosis received daily, supervised therapy with an average of 5.3±1.3 drugs, including cycloserine, an injectable drug, and a fluoroquinolone. Twenty-nine of these patients (60.4%) completed treatment or were cured, as compared with 400 patients (66.3%) with multidrug-resistant tuberculosis (P=0.36). CONCLUSIONS Extensively drug-resistant tuberculosis can be cured in HIV-negative patients through outpatient treatment, even in those who have received multiple prior courses of therapy for tuberculosis.

BackgroundDepressive disorders are frequently under diagnosed in resource‐limited settings because of lack of access to mental health care or the inability of healthcare providers to recognize them. The Patient Health Questionnaire (PHQ)‐2 and the PHQ‐9 have been widely used for screening and diagnosis of depression in primary care settings; however, the validity of their use in rural, Spanish‐speaking populations is unknown.MethodWe used a cross‐sectional design to assess the psychometric properties of the PHQ‐9 for depression diagnosis and estimated the sensitivity and specificity of the PHQ‐2 for depression screening. Data were collected from 223 adults in a rural community of Chiapas, Mexico, using the PHQ‐2, the PHQ‐9, and the World Health Organization Quality of Life BREF Scale (WHOQOL‐ BREF).ResultsConfirmatory factor analysis suggested that the 1‐factor structure fit reasonably well. The internal consistency of the PHQ‐9 was good (Cronbach's alpha > = 0.8) overall and for subgroups defined by gender, literacy, and age. The PHQ‐9 demonstrated good predictive validity: Participants with a PHQ‐9 diagnosis of depression had lower quality of life scores on the overall WHOQOL‐BREF Scale and each of its domains. Using the PHQ‐9 results as a gold standard, the optimal PHQ‐2 cutoff score for screening of depression was 3 (sensitivity 80.00%, specificity 86.88%, area under receiver operating characteristic curve = 0.89; 95% confidence interval [0.84, 0.94]).ConclusionThe PHQ‐2 and PHQ‐9 demonstrated good psychometric properties, suggesting their potential benefit as tools for depression screening and diagnosis in rural, Spanish‐speaking populations.

The proportion of patients who defaulted from MDR TB treatment was relatively low. The large proportion of patients who had culture-positive sputum at the time of treatment default underscores the public health importance of minimizing treatment default. Prognosis for patients who defaulted from therapy was poor. Interventions aimed at preventing treatment default may reduce TB-related mortality.

A program of intensive community-based treatment support for ART in rural Rwanda had excellent outcomes in 24-month retention in care. Having committed to improving access to HIV treatment in sub-Saharan Africa, the international community, including country HIV programs, should set high programmatic outcome benchmarks.