Ambulatory Multi-Drug Resistant Tuberculosis Treatment Outcomes in a Cohort of HIV-Infected Patients in a Slum Setting in Mumbai, India

Abstract

BackgroundIndia carries one quarter of the global burden of multi-drug resistant TB (MDR-TB) and has an estimated 2.5 million people living with HIV. Despite this reality, provision of treatment for MDR-TB is extremely limited, particularly for HIV-infected individuals. Médecins Sans Frontières (MSF) has been treating HIV-infected MDR-TB patients in Mumbai since May 2007. This is the first report of treatment outcomes among HIV-infected MDR-TB patients in India.MethodsHIV-infected patients with suspected MDR-TB were referred to the MSF-clinic by public Antiretroviral Therapy (ART) Centers or by a network of community non-governmental organizations. Patients were initiated on either empiric or individualized second-line TB-treatment as per WHO recommendations. MDR-TB treatment was given on an ambulatory basis and under directly observed therapy using a decentralized network of providers. Patients not already receiving ART were started on treatment within two months of initiating MDR-TB treatment.ResultsBetween May 2007 and May 2011, 71 HIV-infected patients were suspected to have MDR-TB, and 58 were initiated on treatment. MDR-TB was confirmed in 45 (78%), of which 18 (40%) were resistant to ofloxacin. Final treatment outcomes were available for 23 patients; 11 (48%) were successfully treated, 4 (17%) died, 6 (26%) defaulted, and 2 (9%) failed treatment. Overall, among 58 patients on treatment, 13 (22%) were successfully treated, 13 (22%) died, 7 (12%) defaulted, two (3%) failed treatment, and 23 (40%) were alive and still on treatment at the end of the observation period. Twenty-six patients (45%) experienced moderate to severe adverse events, requiring modification of the regimen in 12 (20%). Overall, 20 (28%) of the 71 patients with MDR-TB died, including 7 not initiated on treatment.ConclusionsDespite high fluoroquinolone resistance and extensive prior second-line treatment, encouraging results are being achieved in an ambulatory MDR-T- program in a slum setting in India. Rapid scale-up of both ART and second-line treatment for MDR-TB is needed to ensure survival of co-infected patients and mitigate this growing epidemic.

Adverse Drug Reactions in Patients put on Multi Drug Resistant Tuberculosis (MDR-TB) Treatment in Seven Districts of Central Gujarat

“…15 Another study by Isakidis et al, in Mumbai also noticed that 45% experienced adverse events, of which only 20% required change of regimen. 16 There are several possible explanations for the differences in the number of patients requiring drugs to be removed from the regimen due to ADRs in this study and other studies. These include differences in training, their different experiences with a variety of patients, variation in health care workers ability to detect ADRs and their management.…”

Infection control in households of drug-resistant tuberculosis patients co-infected with HIV in Mumbai, India

“…The general characteristics of the patients in the programme have been reported elsewhere. 18 The mean patient age was 34 years (standard deviation 9.4), and the majority (62%) were male. The median number of adult members per household was 2.5 (interquartile range [IQR] 1-5), and approximately half of the households (14/29) included children, including two with one child aged 5 years.…”

“…More than 70% of the patients enrolled in the MSF programme are slum dwellers, as previously described. 18,19 TB IC assessments and interventions were carried out in households of DR-TB patients co-infected with HIV from May 2012 to March 2013, after patient consent had been obtained.…”

Use of Verbal Autopsy to Determine Underlying Cause of Death during Treatment of Multidrug-Resistant Tuberculosis, India

“…These reports defined TB-related deaths in accordance with the RNTCP treatment outcome variable (i.e., all-cause mortality) and may not reflect the true estimate of deaths attributable to TB. A recent study among a smaller cohort of HIV-infected MDR TB patients treated in Mumbai reported 4 (31%) of 13 deaths were attributed to causes not related to TB or treatment ( 22 ). These data suggest that the RNTCP may be overestimating TB-related deaths among MDR TB patients.…”