title: HIV coinfection in multidrug- and extensively drug-resistant tuberculosis results in high early mortality.
abstract: BACKGROUND
  The multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) epidemics are rapidly expanding in South Africa. Our initial report of HIV-associated XDR TB in South Africa revealed rapid and near complete mortality. Lower mortality has been described in the literature, but few of these patients have been HIV coinfected.
  
  
  OBJECTIVE
  To characterize mortality from MDR and XDR TB in a setting with high HIV-coinfection rates.
  
  
  METHODS
  We conducted a retrospective observational study among 654 MDR and XDR TB cases diagnosed in Tugela Ferry, South Africa, from 2005 to 2007. Demographics and HIV status were abstracted from available medical records.
  
  
  RESULTS
  Survival was determined from the date of sputum collection until October 2008 and correlated with year of diagnosis and drug-susceptibility test results. From 2005 to 2007, 272 MDR TB and 382 XDR TB cases were diagnosed; HIV-coinfection rates were 90 and 98%, respectively. One-year mortality was 71% for MDR and 83% for XDR TB patients; 40% of MDR TB and 51% of XDR TB cases died within 30 days of sputum collection. One-year mortality among both MDR and XDR TB patients improved from 2005 to 2007; however, the majority of deaths still occurred within the first 30 days. One-year and 30-day mortality rates were worse with greater degree of drug resistance (P < 0.001).
  
  
  CONCLUSIONS
  Mortality from MDR and XDR TB in this high HIV-prevalence region is extraordinarily high, particularly within the first 30 days. Efforts to reduce mortality must focus on earlier diagnosis and early initiation of second-line TB and antiretroviral therapy.
authors.affiliation: Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York 10467, USA. neelgandhi@alumni.williams.edu
authors.forename: Neel R
authors.initials: NR
authors.lastname: Gandhi
authors.forename: N Sarita
authors.initials: NS
authors.lastname: Shah
authors.forename: Jason R
authors.initials: JR
authors.lastname: Andrews
authors.forename: Venanzio
authors.initials: V
authors.lastname: Vella
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Moll
authors.forename: Michelle
authors.initials: M
authors.lastname: Scott
authors.forename: Darren
authors.initials: D
authors.lastname: Weissman
authors.forename: Claudio
authors.initials: C
authors.lastname: Marra
authors.forename: Umesh G
authors.initials: UG
authors.lastname: Lalloo
authors.forename: Gerald H
authors.initials: GH
authors.lastname: Friedland
mesh_terms: D000328:Adult; D054908:Extensively Drug-Resistant Tuberculosis / Q000150:complications* / Q000401:mortality; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D013019:South Africa / Q000453:epidemiology