Loss from Treatment for Drug Resistant Tuberculosis: Risk Factors and Patient Outcomes in a Community-Based Program in Khayelitsha, South Africa

Abstract

BackgroundA community based drug resistant tuberculosis (DR-TB) program has been incrementally implemented in Khayelitsha, a high HIV and TB burden community in South Africa. We investigated loss from treatment (LFT), and post treatment outcomes of DR-TB patients in this setting.MethodologyLFT, defined as interruption of treatment for ≥2 consecutive months was assessed among patients initiating DR-TB treatment for the first time between January 2009 and July 2011. Patients were traced through routine data sources to identify those who subsequently restarted treatment and those who died. Additional information on patient status and survival after LTF was obtained from community DR-TB counselors and from the national death registry. Post treatment outcomes were observed until July 2013.ResultsAmong 452 patients initiating treatment for the first time within the given period, 30% (136) were LFT, with 67% retention at 18 months. Treatment was restarted in 27 (20%) patients, with additional resistance recorded in 2/25 (8%), excluding two with presumed DR-TB. Overall, 34 (25%) patients died, including 11 who restarted treatment. Males and those in the age category 15-25 years had a greater hazard of LFT; HR 1.93 (95% CI 1.35-2.75), and 2.43 (95% CI 1.52-3.88) respectively. Older age (>35 years) was associated with a greater hazard of death; HR 3.74 (1.13- 12.37) post treatment. Overall two-year survival was 62%. It was lower (45%) in older patients, and was 92% among those who received >12 months treatment.ConclusionLFT was high, occurred throughout the treatment period and was particularly high among males and those aged 15-25 years. Overall long term survival was poor. High rates of LFT should however not preclude scale up of community based care given its impact in increasing access to treatment. Further research is needed to support retention of DR-TB patients on treatment, even within community based treatment programs.

High rates of multidrug-resistant and rifampicin-resistant tuberculosis among re-treatment cases: where do they come from?

“…In South Africa, transmission of MDR/RR-TB caused around 64% of MDR/RR -TB cases diagnosed at re-treatment, which is supported by molecular epidemiology studies indicating substantial clonal spread of multiple MDR-TB strains [11]. In addition to a strong emphasis on improved treatment adherence, consideration should be given to additional efforts that may reduce TB transmission within disease “hot spots” [31, 32]. …”

The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis

“…483 Counselling and treatment literacy delivered by trained and paid lay health counsellors or drug-resistant tuberculosis survivors are crucial. 484 Such counselling should be individualised and include ongoing assessments of barriers to adherence and strategies for addressing them, because an individual's ability to adhere can change over time depending on his or her life circumstances.…”

“…A study in the Western Cape province of South Africa using cohort data from four South African treatment sites, 483 identified criteria for treatment failure, including duration of uninterrupted treatment for 12 months, three consecutive positive sputa, and a declining clinical condition. Decisions on treatment discontinuation should always be made by a multidisciplinary team, including the individual being treated and his or her support network.…”

Loss to Follow-Up (LTFU) during Tuberculosis Treatment

“…They defined LTFU as "A TB patient who did not start treatment or whose treatment was interrupted for 2 consecutive months or more." Since then, several papers have started reporting according to this new term and definition [3][4][5][6][7][8][9][10].…”

“…Among the various sociodemographic characteristics, age is a recognized factor associated with LTFU. Studies from India, Brazil, and China revealed that elderly patients have higher LTFU [4,[68][69][70], whereas studies from Norway, Botswana, and South Africa suggested that adolescents have significant risk [8,30,71]. One study from the UK even suggested a wider range of age of 15-44 years as a high-risk group for LTFU [11].…”