Treatment Outcomes for Extensively Drug-Resistant Tuberculosis and HIV Co-infection - Vol. 19 No. 3 - March 2013 - Emerging Infectious Disease journal - CDC

full-text ►
Treatment Outcomes for Extensively Drug-Resistant Tuberculosis and HIV Co-infection - Vol. 19 No. 3 - March 2013 - Emerging Infectious Disease journal - CDC


Table of Contents
Volume 19, Number 3– March 2013

Volume 19, Number 3—March 2013

Research

Treatment Outcomes for Extensively Drug-Resistant Tuberculosis and HIV Co-infection

Article Contents

• Methods
• Results
• Discussion
• Acknowledgments
• References
• Figure 1
• Figure 2
• Table 1
• Table 2
• Table 3
• Table 4
• Table 5
• Table 6
• Suggested Citation

Max R. O’Donnell , Nesri Padayatchi, Charlotte Kvasnovsky, Lise Werner, Iqbal Master, and C. Robert Horsburgh

Author affiliations: Author affiliations: Albert Einstein College of Medicine, Bronx, New York, USA (M.R. O’Donnell); Centre for AIDS Programme of Research in South Africa, Durban, South Africa (M.R. O’Donnell, N. Padayatchi, L. Werner); University of Maryland School of Medicine, Baltimore, Maryland, USA (C. Kvasnovsky); King George V Hospital, Sydenham, South Africa (I. Master); Boston University School of Public Health, Boston, Massachusetts, USA (C.R. Horsburgh, Jr.); Boston University School of Medicine, Boston (C.R. Horsburgh, Jr.)

Suggested citation for this article

Abstract

High mortality rates have been reported for patients co-infected with extensively drug-resistant tuberculosis (XDR-TB) and HIV, but treatment outcomes have not been reported. We report treatment outcomes for adult XDR TB patients in KwaZulu-Natal Province, South Africa. Initial data were obtained retrospectively, and outcomes were obtained prospectively during 24 months of treatment. A total of 114 XDR TB patients were treated (median 6 drugs, range 3–9 drugs); 82 (73%) were HIV positive and 50 (61%) were receiving antiretroviral therapy. After receiving treatment for 24 months, 48 (42%) of 114 patients died, 25 (22%) were cured or successfully completed treatment, 19 (17%) withdrew from the study, and 22 (19%) showed treatment failure. A higher number of deaths occurred among HIV-positive patients not receiving antiretroviral therapy and among patients who did not show sputum culture conversion. Culture conversion was a major predictor of survival but was poorly predictive (51%) of successful treatment outcome.

Drug-resistant tuberculosis (TB) is a critical threat to TB control and global public health (1–3). Nowhere is this threat more pressing than in South Africa, where drug-resistant TB and HIV have converged in a deadly syndemic defined by increased incidences of TB and HIV (4), endemic transmission of drug-resistant TB strains (5), high mortality rates (6), and poor treatment outcomes (7). The most drug-resistant form of TB, extensively drug-resistant tuberculosis (XDR TB) (8) has been reported in 70 countries and comprises an increasing proportion of drug-resistant TB cases (1).
The global epicenter of the XDR TB and HIV syndemic is KwaZulu-Natal Province in South Africa, where nearly 400 XDR TB patients, 70% co-infected with HIV, were admitted to a provincial TB referral hospital for initiation of therapy during 2003–2008 (9). To contextualize this incidence, 73% (573/782) of all XDR TB cases reported to the World Health Organization globally during 2002–2009 were from South Africa (3,10). It is estimated that 50% of patients with a diagnosis of XDR TB in KwaZulu-Natal Province do not survive to treatment referral (11). Therefore, hospital-based surveillance represents a major underestimate of cases of co-infection with XDR TB and HIV in the province.
Without adequate second-line TB and HIV treatment, reported mortality rates for persons co-infected with XDR TB and HIV approach 100% (6). Among XDR TB patients who survive to initiation of second-line TB therapy, early treatment outcomes reported by our group and others describe low rates of sputum culture conversion, major adverse events, and a substantial number of early deaths (12–14). To our knowledge there are no published reports of outcomes for patients co-infected with XDR TB and HIV at the end of TB treatment. This report describes treatment outcomes, adverse events, and risk factors for death among patients in South Africa with XDR TB, most of whom were co-infected with HIV.