title: Poor outcomes in a cohort of HIV-infected adolescents undergoing treatment for multidrug-resistant tuberculosis in Mumbai, India.
abstract: BACKGROUND
  Little is known about the treatment of multidrug-resistant tuberculosis (MDR-TB) in HIV-co-infected adolescents. This study aimed to present the intermediate outcomes of HIV-infected adolescents aged 10-19 years receiving second-line anti-TB treatment in a Médecins Sans Frontières (MSF) project in Mumbai, India.
  
  
  METHODS
  A retrospective review of medical records of 11 adolescents enrolled between July 2007 and January 2013 was undertaken. Patients were initiated on either empirical or individualized second-line ambulatory anti-TB treatment under direct observation.
  
  
  RESULTS
  The median age was 16 (IQR 14-18) years and 54% were female. Five (46%) adolescents had pulmonary TB (PTB), two (18%) extrapulmonary disease (EPTB) and four (36%) had both. Median CD4 count at the time of MDR-TB diagnosis was 162.7 cells/µl (IQR: 84.8-250.5). By January 2013, eight patients had final and 3 had interim outcomes. Favourable results were seen in four (36.5%) patients: one was cured and three were still on treatment with negative culture results. Seven patients (64%) had poor outcomes: four (36.5%) died and three (27%) defaulted. Three of the patients who died never started on antiretroviral and/or TB treatment and one died 16 days after treatment initiation. Two of the defaulted died soon after default. All patients (100%) on-treatment experienced adverse events (AEs): two required permanent discontinuation of the culprit drug and two were hospitalized due to AEs. No patient required permanent discontinuation of the entire second-line TB or antiretroviral regimens.
  
  
  CONCLUSIONS
  Early mortality and mortality after default were the most common reasons for poor outcomes in this study. Early mortality suggests the need for rapid diagnosis and prompt treatment initiation, and adolescents might benefit from active contact-tracing and immediate referral. Default occurred at different times, suggesting the need for continuous, intensified and individualized psychosocial support for co-infected adolescents. Operational research among co-infected adolescents will be especially important in designing effective interventions for this vulnerable group.
authors.affiliation: Médecins Sans Frontières, Mumbai, India. msfocb-asia-epidemio@brussels.msf.org
authors.forename: Petros
authors.initials: P
authors.lastname: Isaakidis
authors.forename: Roma
authors.initials: R
authors.lastname: Paryani
authors.forename: Samsuddin
authors.initials: S
authors.lastname: Khan
authors.forename: Homa
authors.initials: H
authors.lastname: Mansoor
authors.forename: Mamta
authors.initials: M
authors.lastname: Manglani
authors.forename: Asmaa
authors.initials: A
authors.lastname: Valiyakath
authors.forename: Peter
authors.initials: P
authors.lastname: Saranchuk
authors.forename: Jennifer
authors.initials: J
authors.lastname: Furin
mesh_terms: D000293:Adolescent; D000995:Antitubercular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D002648:Child; D060085:Coinfection; D005260:Female; D015658:HIV Infections; D006801:Humans; D007194:India; D008297:Male; D012189:Retrospective Studies; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy* / Q000401:mortality; D055815:Young Adult
chemical_list: D000995:Antitubercular Agents
references.citation: Curr Opin Pulm Med. 2005 May;11(3):189-94
references.pmid: 15818178
references.citation: J Adolesc Health. 2012 Sep;51(3):242-51
references.pmid: 22921134
references.citation: Pediatrics. 2006 Jun;117(6):2022-9
references.pmid: 16740844
references.citation: Lancet Infect Dis. 2012 Jun;12(6):449-56
references.pmid: 22373593
references.citation: J Adv Nurs. 2012 Nov;68(11):2399-409
references.pmid: 22272919
references.citation: J Dev Behav Pediatr. 2012 May;33(4):298-308
references.pmid: 22366661
references.citation: Ann Intern Med. 2012 Sep 4;157(5):313-24
references.pmid: 22944873
references.citation: S Afr Med J. 2007 Oct;97(10 Pt 2):995-7
references.pmid: 18000589
references.citation: PLoS One. 2011;6(12):e28066
references.pmid: 22145022
references.citation: Pediatr Infect Dis J. 2012 Feb;31(2):129-33
references.pmid: 22016079
references.citation: PLoS One. 2012;7(7):e40781
references.pmid: 22792406
references.citation: Clin Infect Dis. 2012 Jan 15;54(2):157-66
references.pmid: 22052896
references.citation: AIDS Patient Care STDS. 2012 Jul;26(7):423-9
references.pmid: 22686235
references.citation: PLoS One. 2012;7(6):e39134
references.pmid: 22720052
references.citation: Lancet. 2004 Feb 7;363(9407):474-81
references.pmid: 14962530
references.citation: Int J Tuberc Lung Dis. 1999 May;3(5):365-7
references.pmid: 10331723
references.citation: AIDS Care. 2012;24(10):1204-10
references.pmid: 22380932
references.citation: Afr J Psychiatry (Johannesbg). 2011 Nov;14(5):383-7
references.pmid: 22183469
references.citation: N Engl J Med. 2008 Aug 7;359(6):563-74
references.pmid: 18687637
references.citation: Int J Tuberc Lung Dis. 2010 Jul;14(7):878-83
references.pmid: 20550772
references.citation: Indian J Med Res. 2012 May;135(5):690-4
references.pmid: 22771603
references.citation: Int J Tuberc Lung Dis. 2011 Oct;15(10):1326-30
references.pmid: 22283889
references.citation: N Engl J Med. 2003 Jan 9;348(2):119-28
references.pmid: 12519922
references.citation: J Bras Pneumol. 2011 May-Jun;37(3):288-93
references.pmid: 21755182
references.citation: BMC Infect Dis. 2011 Jan 26;11:28
references.pmid: 21269475
references.citation: Inflamm Bowel Dis. 2012 Jul;18(7):1254-9
references.pmid: 22689633
references.citation: Am J Respir Crit Care Med. 2010 Jan 1;181(1):80-6
references.pmid: 19833824
references.citation: Pediatr Infect Dis J. 2009 May;28(5):416-9
references.pmid: 19352212
references.citation: Curr Opin Pediatr. 2012 Jun;24(3):319-28
references.pmid: 22568943
references.citation: Cochrane Database Syst Rev. 2012 May 16;(5):CD006591
references.pmid: 22592714
references.citation: BMC Infect Dis. 2011 Dec 16;11:351
references.pmid: 22176628
references.citation: N Engl J Med. 2008 Aug 7;359(6):657-9
references.pmid: 18687654
references.citation: Gastroenterol Nurs. 2012 Jul-Aug;35(4):248-54
references.pmid: 22847283
references.citation: Int J Tuberc Lung Dis. 2012 Oct;16(10):1371-6
references.pmid: 22863182