title: Community-based treatment of drug-resistant tuberculosis in Khayelitsha, South Africa.
abstract: METHODS
  Khayelitsha, South Africa, a peri-urban township with high burdens of tuberculosis (TB), drug-resistant tuberculosis (DR-TB), and human immunodeficiency virus (HIV) infection.
  
  
  OBJECTIVE
  To describe case detection and patient outcomes in a community-based DR-TB programme.
  
  
  METHODS
  DR-TB management was integrated into primary health care in Khayelitsha from 2007 onwards. Implementation was incremental, and included training and clinician support, counselling and home visits, tuberculous infection control, a local in-patient service, and routine monitoring. Patients received treatment rapidly through their local clinic, and were only hospitalised if clinically unwell.
  
  
  RESULTS
  DR-TB case notification (any rifampicin resistance) increased from 28 per 100 000 population per year (2005-2007) to 55/100 000/year in 2009-2011 (72% HIV-infected). From 2008 to 2011, 754 patients received treatment (86% of those diagnosed). The median time between diagnostic sputum and treatment decreased over the years of implementation to 27 days in 2011 (P < 0.001). Treatment success was 52% in 2010, with 31% default, 13% death and 4% treatment failure. Two-year survival was 65%, with poorer survival in those with HIV (HR 2.0, 95%CI 1.4-2.8), second-line drug resistance (HR 3.3, 95%CI 2.2-4.8), and diagnosis in earlier programme years (HR 1.4, 95%CI 1.1-2.0).
  
  
  CONCLUSIONS
  Community-based DR-TB management is feasible, and contributes to improved case detection, reduced treatment delay and improved survival. Treatment outcomes remain poor, highlighting the poor efficacy, tolerability and lengthy duration of current treatment.
authors.affiliation: Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: H
authors.initials: H
authors.lastname: Cox
authors.affiliation: Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: J
authors.initials: J
authors.lastname: Hughes
authors.affiliation: Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: J
authors.initials: J
authors.lastname: Daniels
authors.affiliation: City of Cape Town Health Department, Khayelitsha, Cape Town, South Africa.
authors.forename: V
authors.initials: V
authors.lastname: Azevedo
authors.affiliation: Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: C
authors.initials: C
authors.lastname: McDermid
authors.affiliation: Western Cape Province Department of Health, Cape Town, South Africa South Africa.
authors.forename: M
authors.initials: M
authors.lastname: Poolman
authors.affiliation: Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.
authors.forename: A
authors.initials: A
authors.lastname: Boulle
authors.affiliation: Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: E
authors.initials: E
authors.lastname: Goemaere
authors.affiliation: Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: G
authors.initials: G
authors.lastname: van Cutsem
mesh_terms: D000293:Adolescent; D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use*; D060085:Coinfection; D003153:Community Health Services; D024901:Drug Resistance, Multiple, Bacterial; D005240:Feasibility Studies; D005260:Female; D015658:HIV Infections / Q000453:epidemiology; D006801:Humans; D008297:Male; D009169:Mycobacterium tuberculosis / Q000187:drug effects* / Q000302:isolation & purification; D010865:Pilot Projects; D015995:Prevalence; D015397:Program Evaluation; D012189:Retrospective Studies; D013019:South Africa / Q000453:epidemiology; D013183:Sputum / Q000382:microbiology; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D019037:Urban Health Services; D055815:Young Adult
chemical_list: D000995:Antitubercular Agents