High MDR-TB treatment success rates among people on ART

High treatment success rates among HIV-infected multidrug-resistant tuberculosis patients after expansion of antiretroviral therapy in Botswana, 2006-2013.

Shin SS, Modongo C, Boyd R, Caiphus C, Kuate L, Kgwaadira B, Zetola NM. J Acquir Immune Defic Syndr. 2017 Jan 1;74(1):65-71.

Background: Few studies have examined multidrug-resistant (MDR) tuberculosis (TB) treatment outcomes among HIV-infected persons after widespread expansion of antiretroviral therapy (ART). We describe MDR-TB treatment outcomes among HIV-infected and HIV-uninfected patients in Botswana after ART expansion.

Methods: We retrospectively reviewed data from patients who started MDR-TB therapy in Botswana during 2006-2013. Multivariable regression models were used to compare treatment outcomes between HIV-infected and HIV-uninfected patients.

Results: We included 588 MDR-TB patients in the analysis, of whom, 47 (8.0%) and 9 (1.5%) were diagnosed with pre-extensively drug-resistant (XDR)-TB and XDR-TB, respectively. Of the 408 (69.4%) HIV-infected patients, 352 (86.0%) were on ART or started ART during treatment, and median baseline CD4 T-cell count was 234 cells/mm3. Treatment success rates were 79.4% and 73.0% among HIV-uninfected and HIV-infected patients, respectively (P = 0.121). HIV-infected patients with CD4 T-cell count <100 cells/mm3 were more likely to die during treatment compared with HIV-uninfected patients (adjusted risk ratio = 1.890; 95% CI: 1.098 to 3.254).

Conclusions: High rates of treatment success were achieved with programmatic management of MDR-TB and HIV in Botswana after widespread expansion of ART. However, a 2-fold increase in mortality was observed among HIV-infected persons with baseline CD4 <100 cells/mm3 compared with HIV-uninfected persons.

Abstract access   [1]

Editor’s notes: This article describes the treatment outcomes of multidrug-resistant tuberculosis (MDR-TB) among HIV-positive and HIV-negative people in Botswana between 2006 and 2013, after expansion of the antiretroviral therapy (ART) programme. The investigators used programmatic data for their analysis, and the results therefore reflect “real-life” experience of people in the MDR-TB programme.

The authors found very high rates of treatment success. Some 75% of people started on MDR-TB treatment achieved treatment success, and among people living with HIV the success rate was 73%. This is significantly higher than the 57% treatment success reported in a recent systematic review of HIV-positive MDR-TB people. Pre-treatment counselling, strict directly observed therapy, food and transport incentives, follow-up of people who missed their monthly consultations are all aspects of the MDR-TB (and ART programme) that may have contributed to these high success rates. On the other hand, the inclusion of studies done before widespread access to ART may have contributed to the lower success rates reported in the systematic review. 

The reported treatment success of 79% among HIV-negative people was lower than the 84-89% treatment success reported for the new nine-month MDR-TB regimen endorsed by WHO. However, the authors emphasize that additional research is necessary to evaluate the effectiveness of the nine-month regimen in a similar setting as Botswana, where the majority of MDR-TB people are HIV-positive.

In this study, about 70% of MDR-TB people were HIV-positive, and 20% of people had a CD4 count of less than 100 cells/mm3 at the time of MDR-TB treatment initiation. People with a CD4 less than 100 cells/mm3 were almost twice as likely to die during their MDR-TB treatment compared to HIV-negative people. People living with HIV, with CD4<100 cells/mm3 often have co-morbidities, and are at high risk of dying of diseases other than TB, including cryptococcal meningitis and other opportunistic infections. The authors suggest that additional research is necessary to improve the clinical management of MDR-TB people with advanced immunosuppression.

The authors conclude that to reduce mortality from MDR-TB and other causes, increased efforts are necessary to reach all people living with HIV with ART as part of comprehensive HV care. In June 2016, Botswana launched the “Test and Treat” programme, to provide ART to all people living with HIV, which should contribute to this goal. 

Comorbidity [3], Epidemiology [4], HIV Treatment [5]
Africa [6]
Botswana [7]
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