Model of care and risk factors for poor outcomes in patients on multi-drug resistant tuberculosis treatment at two facilities in eSwatini (formerly Swaziland), 2011–2013

Abstract

IntroductionSince 2011 Médecins sans Frontières together with the eSwatini Ministry of Health have been managing patients with multi-drug resistant tuberculosis (MDR-TB) at Matsapha and Mankayane in Manzini region. This analysis describes the model of care and outcomes of patients receiving a 20 months MDR-TB treatment regimen between 2011 and 2013.MethodWe conducted a retrospective observational cohort study of MDR-TB patients enrolled for treatment between May 2011 and December 2013. An extensive package of psychological care and socio-economic incentives were provided including psychological support, paid treatment supporters, transport fees and a monthly food package. Baseline demographic details and treatment outcomes were recorded and for HIV positive patient’s univariate analysis as well as a cox regression hazard model were undertaken to assess risk factors for unfavorable outcomes.ResultsFrom the 174 patients enrolled, 156 (89.7%) were HIV co-infected, 102 (58.6%) were female, median age 33 years old (IQR: 28–42), 55 (31.6%) had a BMI less than 18 and 86 (49.4%) had not been previously treated for any form of TB. Overall cohort outcomes revealed a 75.3% treatment success rate, 21.3% mortality rate, 0.6% failure and 0.6% lost to follow-up rate. In the adjusted multivariate analysis, low BMI and low CD4 count at treatment initiation were associated with an increased risk of unfavorable outcome.ConclusionsA model of care that included psychosocial support and patient’s enablers led to a high level of treatment success with a very low lost to follow up rate. Limiting the overall treatment success was a high mortality rate which was associated with advanced HIV and a low BMI at presentation. These factors will need to be addressed in order to improve upon the overall treatment success rate in future.

Treatment outcomes of multi drug resistant and rifampicin resistant Tuberculosis in Zimbabwe: A cohort analysis of patients initiated on treatment during 2010 to 2015

“…[23,24] It is likely that such ART-naïve HIV co-infected patients were presenting with severe immunosuppression and hence denied the well-known benefits of life-saving ART in restoring their immune function. [21,22] Thus, the finding highlights the importance of ART in limiting the unfavourable treatment outcomes among MDR/RR-TB patients in high HIV burden countries.…”

“…In contrast, better treatment success rates of around 75% have been observed in similar cohorts in Botswana and eSwatini with similar high HIV and MDR/RR-TB co-infection MDR/RR-TB cohorts. [21,22] However, the patient in Botswana and eSwatini had received social support in the form of monetary incentives or nutritional and transportation support including psychological support at health facilities. No such social and psychological support mechanisms were made available in the current study setting and should be considered in the future for improving treatment outcomes.…”

Successful expansion of community‐based drug‐resistant TB care in rural Eswatini – a retrospective cohort study

“…Solely clinic‐based care approaches would probably have left behind patients from remote locations. Other community‐based care models used nurses living near patients’ homes or nurse‐led mobile injection teams for daily home visits, DOT and treatment provision . In our setting, patients received a monthly supply of oral and injectable drugs, and CTS ensured daily treatment provision, requiring fewer supervisory visits by health professionals.…”

Factors associated with unfavourable treatment outcomes among people with rifampicin-resistant tuberculosis in Armenia, 2014-2017

“…Globally, many risk factors for unfavourable treatment outcomes of RR/MDR-TB patients have been identified [6]. These include HIV co-infection, diabetes mellitus, poor treatment adherence, delay in TB treatment initiation and history of previous TB treatment [6][7][8][9][10][11][12][13][14][15][16][17]. Evidence from Armenia on this topic is limited: previous studies have reported socio-economic factors such as education, income and occupation, and adverse drug events as the key factors for poor outcomes among MDR-TB patients [9,18,19].…”