Integrated, home-based treatment for MDR-TB and HIV in rural South Africa: an alternate model of care.
METHODS
Treatment outcomes for multidrug-resistant tuberculosis (MDR-TB) in South Africa have suffered as centralized, in-patient treatment programs struggle to cope with rising prevalence and human immunodeficiency virus (HIV) co-infection rates. A new treatment model is needed to  expand treatment capacity and improve MDR-TB and HIV outcomes.


OBJECTIVE
To describe the design and preliminary results of an integrated, home-based MDR-TB-HIV treatment program created in rural KwaZulu-Natal.


METHODS
In 2008, a decentralized center was established to provide out-patient  MDR-TB and HIV treatment. Nurses, community health workers and family supporters have been trained to administer injections, provide adherence support and monitor adverse reactions in patients' homes. Physicians assess clinical response, adherence and the severity of adverse reactions to MDR-TB  and HIV treatment at monthly follow-up visits. Treatment outcomes are assessed by monthly cultures and CD4 and viral load every 6 months.


RESULTS
Of 80 patients initiating MDR-TB treatment from February 2008 to April 2010, 66 were HIV-co-infected. Retention has been high (only 5% defaults,  93% of visits attended), and preliminary outcomes have been favorable (77% cured/still on treatment, 82% undetectable viral load). Few patients have required escalation of care (9%), had severe adverse events (8%) or died (6%).


CONCLUSIONS
Integrated, home-based treatment for MDR-TB and  HIV is a promising treatment model to expand capacity and achieve improved outcomes in rural, resource-poor and high HIV prevalent settings.
Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York 10467, USA. jcmbrust@gmail.com
J C M
JC
Brust
N S
NS
Shah
M
M
Scott
K
K
Chaiyachati
M
M
Lygizos
T L
TL
van der Merwe
S
S
Bamber
Z
Z
Radebe
M
M
Loveday
A P
AP
Moll
B
B
Margot
U G
UG
Lalloo
G H
GH
Friedland
N R
NR
Gandhi
D000328:Adult; D000553:Ambulatory Care / Q000458:organization & administration*; D019380:Anti-HIV Agents / Q000009:adverse effects / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D018791:CD4 Lymphocyte Count; D017028:Caregivers; D060085:Coinfection; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005240:Feasibility Studies; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D007722:Health Knowledge, Attitudes, Practice; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D008297:Male; D055118:Medication Adherence; D009937:Organizational Objectives; D010348:Patient Care Team / Q000458:organization & administration; D016730:Program Development; D015397:Program Evaluation; D019035:Rural Health Services / Q000458:organization & administration*; D012944:Social Support; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D019562:Viral Load
D019380:Anti-HIV Agents; D000995:Antitubercular Agents