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6 Treatment of Drug-Resistant TB
6 Treatment of Drug-Resistant TB
Pages 55-72
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From page 55... ...
• The success of community-based care for drug-resistant TB in South Africa has led to greater support for decentralized treatment programs. • Antiretroviral therapy has a substantial protective effect for TB.
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From page 56... ...
TREATMENT OF DRUG-RESISTANT TB General Principles Presenters offered general principles for the treatment of drug-resistant TB, including the need for a comprehensive approach that includes intensified case finding, preventive therapy, improved treatment literacy, and good infection control. In addition, presenters suggested that patients should have increased access to anti-TB drugs as well as other treatment modalities, including thoracic surgery and immune modulators.
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From page 57... ...
This remains a huge public health problem in South Africa and particularly in KwaZulu-Natal, where the cure rates are below 50 percent. Figures from 2005 to 2007 in Tugela Ferry show that by 30 days from sputum collection, the mortality rates in MDR and XDR TB patients were
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From page 58... ...
Among those who survived 2 months on second-line drugs, survival rates were higher for those on antiretroviral therapy and those with CD4 cell counts above 200. Decentralized management will allow earlier access to care and initiation of treatment of MDR and XDR TB, as well as HIV coinfection, at decentralized sites (O'Donnell et al., 2009)
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From page 59... ...
at 12 months of treatment or upon the death of a patient. The objectives of the study were • to describe the characteristics of HIV-negative and HIV-positive patients with XDR TB in the Eastern Cape, • to determine patient mortality after 12 months on XDR TB treatment, • to elucidate risk factors for early mortality, • to ascertain the role of HIV in mortality due to XDR TB, and • to consider the effect of treatment regimens on patients with XDR TB.
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From page 60... ...
Therefore, although the current protocol in South Africa is to start antiretroviral therapy when the CD4 count is under 200 and after the first month of XDR TB treatment, Kvasnovsky recommended the early initiation of antiretroviral therapy in all HIV-positive patients irrespective of CD4 count.2 2 South Africa updated its guidelines for antiretroviral therapy to give priority to treatment of individuals coinfected with TB and HIV. Taking effect in April 2010, the national eligibility criteria for adults and adolescents to start antiretroviral therapy regimens include HIV−drugsusceptible TB patients with a CD4 count below 350, as well as all MDR and XDR TB patients coinfected with HIV, regardless of CD4 count.
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From page 61... ...
As follow-up, the Ethiopian MDR TB team attended MDR TB training in Cambodia led by the Cambodian Health Committee. This program involved both didactic and hands-on training in the Cambodian Health Committee's hospital-, community-, and home-based MDR TB care program.
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From page 62... ...
The Cambodian Health Committee subsequently obtained second-line drugs for MDR TB through the GLC process and initiated treatment for 136 patients throughout the country by March 2010. Twenty percent of these patients were initiated on MDR TB therapy at home in accordance with the community- and home-based models.
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From page 63... ...
Barry reported on a study begun in 2005 at the center, which involves collecting all the strains from patients infected with MDR TB, determining host genetic information, and characterizing different responses to therapy in a large cohort of infected patients. An extensive database of information has been collected by following patients essentially for life.
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From page 64... ...
Genotypic drug susceptibility testing has performed well in predicting clinical outcomes, as measured by 6-month sputum conversion. Treatment and Management of HIV-Associated MDR TB Padayatchi discussed the recently published SAPiT (Starting Antiretroviral therapy at three Points in Tuberculosis therapy)
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From page 65... ...
From October 2006 to June 2007, second-line drug susceptibility testing was available only for patients on MDR TB treatment. After July 2007, isolates from all newly diagnosed MDR TB patients received such testing as well.
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From page 66... ...
Lawn noted that current WHO guidelines recommend that antiretroviral therapy be initiated in all HIV-infected individuals with active TB as soon as practicable after the start of TB treatment, irrespective of CD4 cell count (WHO, 2010c) .4 4 South Africa's national guidelines for antiretroviral (ARV)
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From page 67... ...
Patients thus need to be monitored for cotoxicities and IRIS, said Lawn. An early start on antiretroviral therapy can lead to toxicity problems, but given the positive effect of antiretroviral therapy on lowering mortality and morbidity rates, an option to be treated early is necessary.
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From page 68... ...
Much more needs to be known about resistance patterns for TB strains throughout southern Africa to support the development of individualized treatment regimens, he noted. Barry pointed out that XDR TB is not a biological descriptor of the strain; the question that should be asked is how the structure has changed and what is seen in the patient.
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From page 69... ...
The teams administer injections, monitor side effects, support treatment, refer complications to the unit, and continue patient and family education in TB and infection control. The teams are assisted by DOTS supporters or family members who are trained as treatment supporters.
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From page 70... ...
Lerole David Mametja, Department of Health, South Africa, stressed the need for financial support. When WHO reviewed South Africa's TB control program in July 2009, it estimated that 1 percent of the population or approximately 490,000 South Africans had TB in 2008 and that 2 percent of the TB cases were MDR.
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From page 71... ...
In fact, patients are spreading resistant strains for almost 2 years until drugs arrive. Gandhi observed that since 2007, Tugela Ferry has seen a major influx of resources, primarily financial, that have allowed staffing for the TB treatment program to be increased.
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