title: Strategies for reducing treatment default in drug-resistant tuberculosis: systematic review and meta-analysis.
abstract: BACKGROUND
  Scaling up treatment for multidrug-resistant tuberculosis is a global health priority. However, current treatment regimens are long and associated with side effects, and default rates are consequently high. This systematic review aimed to identify strategies for reducing treatment default.
  
  
  METHODS
  We conducted a systematic search up to May 2012 to identify studies describing interventions to support patients receiving treatment for multidrug-resistant tuberculosis (MDR-TB). The potential influence of study interventions were explored through subgroup analyses.
  
  
  RESULTS
  A total of 75 studies provided outcomes for 18,294 patients across 31 countries. Default rates ranged from 0.5% to 56%, with a pooled proportion of 14.8% (95%CI 12.4-17.4). Strategies identified to be associated with lower default rates included the engagement of community health workers as directly observed treatment (DOT) providers, the provision of DOT throughout treatment, smaller cohort sizes and the provision of patient education.
  
  
  CONCLUSIONS
  Current interventions to support adherence and retention are poorly described and based on weak evidence. This review was able to identify a number of promising, inexpensive interventions feasible for implementation and scale-up in MDR-TB programmes. The high default rates reported from many programmes underscore the pressing need to further refine and evaluate simple intervention packages to support patients.
authors.affiliation: Faculty of Medicine, Imperial College London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Toczek
authors.forename: H
authors.initials: H
authors.lastname: Cox
authors.forename: P
authors.initials: P
authors.lastname: du Cros
authors.forename: G
authors.initials: G
authors.lastname: Cooke
authors.forename: N
authors.initials: N
authors.lastname: Ford
mesh_terms: D000995:Antitubercular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D023801:Directly Observed Therapy; D024901:Drug Resistance, Multiple, Bacterial; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D055118:Medication Adherence; D010353:Patient Education as Topic; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology
chemical_list: D000995:Antitubercular Agents