Standard of Care for MDR-TB

Hind Satti, MDPartners In Health

Lesotho

Lesotho: Basic Facts

• Landlocked country located within South Africa (bordering Free State and KwaZulu-Natal)

• Population 1.8 million• 12,275 TB new cases notified in 2009• Over 2000 re treatment cases • HIV prevalence rate: 23.2% in 2005• 80% of TB cases are HIV positive (NTP 2008)

TB Situation in Lesotho

• Estimated prevalence of 544/100,000 population

• Estimated annual incidence for all cases is 691 per 100,000 population

• Estimated incidence of Sputum smear positive cases is 281 per 100,000 population

• Estimated all TB deaths is 107/100,000 annually

Lesotho MDR-TB Programme

• A comprehensive response to MDR-/XDR-TB in Lesotho, established by the MOHSW.

• International partners include PIH, WHO, FIND, OSI

• Community-based treatment and care model that includes all 10 districts

• First patients enrolled in August 2007; 500 patients enrolled to date

National TB Reference Laboratory

Case Detection

• All HCWs including NTP staff– TB/HIV coordinators/Officers at district hospitals – Health centre nurses providing HIV/TB care

• Routine HIV screening of MDR-TB patients, partners, family members

• Protocol for “medium-risk” and “high-risk”• Sputum sent to national TB laboratory • Screening of household contacts

Botsabelo MDR-/XDR-TB Hospital

Patient Characteristics

• Approximately 78% HIV-positive with advanced AIDS-defining conditions

• Severe malnutrition• Multiple failed TB

treatment regimens• Extensive TB disease• Mostly smear-positive

Inpatient Care

• Very sick patients mostly co infected – Bedridden– Severely wasted

• Severe side effects– Severe hypokalemia– Acute renal failure

• Severe OIs– Meningitis– Esophageal candidiasis

Lesotho vs. rest of the world†

*Tomsk, Latvia, Estonia, Peru, Philippines

† Nathanson et al. Adverse events in the treatment of multidrug-resistant tuberculosis: results from the DOTS-Plus initiative. Int J Tuberc Lung Dis 2004. 8(11):1382–1384

Standardized MDR-TB Regimen

• Pyrazinamide• Kanamycin• Levofloxacin• Prothionamide• Cycloserine • PAS

Infection Control

• Outpatient– TB clinics and general outpatient clinics– Treatment supporters– Family members

• Inpatient– Cross-infection of patients– Protection of health workers (TB and HIV)

Social assistance

MDR-TB/HIV

• 100% HIV testing during the first visit.• Early initiation of HARRT for MDRTB/HIV

(10-21 days), regardless of CD4 count.• Aggressive management of side effects. • Home assessment visit before initiation.• Household contact screening and testing

for TB and HIV.

Adherence

• Adherence crucial in successful treatment of drug-resistant TB

• Barriers to adherence are socioeconomic and must be addressed

• Adverse effects also contribute to poor adherence

Selection of Treatment Supporters

• Lives close to the patient• Accepted by patient and

family• Willing to support patient

for at least 2 years• Willing to accompany

patient to all clinical visits• Attend monthly trainings• Willing to provide

psychosocial support• Not immunocompromised

Role of Treatment Supporter

• Observe all doses • Report side effects• Provide injections.• Accompany patient for

clinical evaluations• Screen for TB and HIV

in household contacts.• Offer psychosocial

support to the patient and the family.

Lesotho National MDR-TB Program

• Currently 550 patients enrolled in community-based treatment

• High incidence of side effects • Comprehensive and integrated

management (HTN, DM, FP, etc.)• Social support, cooperatives, microfinance

Effect of HIV on MDR-TB mortality

Seung KJ, Omatayo DB, Keshavjee S, Furin JJ, Farmer PE, Satti H. Early outcomes of MDR-TB treatment in a high HIV-prevalence setting in Southern Africa. PLoS One. 2009 Sep 25;4(9):e7186.

Conclusion

• Diagnosis and management of MDR-TB in high HIV-prevalence settings is challenging but possible

• Empiric treatment of MDR-TB is needed to decrease early mortality

• Side effects are more common and earlier• Infection control at all levels: hospital, clinic,

community is critical.• Community-based MDR-TB/HIV allows for rapid

enrollment and closer monitoring of side effects

Key Research Areas

• Are there more effective drugs? • Do co-infected patients have

malaborption?• Can treatment be shorter? • Can treatment be safer (less side effects)?• What is the best timing of HAART?• Are there any drug interactions with

HAART?