title: Adherence in the treatment of patients with extensively drug-resistant tuberculosis and HIV in South Africa: a prospective cohort study.
abstract: OBJECTIVE
  Extensively drug-resistant tuberculosis (XDR-TB)/HIV coinfection is difficult to treat with frequent adverse drug reactions and associated with high mortality. Adherence to antiretroviral therapy (ARV) and second-line TB medications may reduce mortality, prevent amplification of drug resistance, and improve outcomes.
  
  
  METHODS
  Prospective cohort study of XDR-TB patients on treatment in KwaZulu-Natal, South Africa. Adherence to ARV and TB medications was assessed separately at baseline and monthly. Knowledge, attitudes, and beliefs were assessed at baseline. Optimal adherence was defined as self-report of taking all pills in the previous 7 days; missing any pills was defined as suboptimal adherence. Primary outcome was optimal adherence 6 months after initiation of XDR-TB treatment to TB medications, ARV, and both ("dual adherence").
  
  
  RESULTS
  One hundred four XDR-TB patients (79.8% HIV coinfected, 84.3% on ARV at enrollment) were enrolled and followed monthly (median 8 visits; interquartile range: 4-12). Six-month optimal adherence was higher for ARV (88.2%) than TB medications (67.7%) (P < 0.001). Low educational attainment, male gender, and year of enrollment were independently associated with dual suboptimal adherence. At baseline, participants indicated that XDR-TB was curable (76.0%), HIV and TB were linked (81.7%), and ARV improves TB outcomes (72.1%). Baseline knowledge, attitudes, and beliefs did not predict subsequent adherence.
  
  
  CONCLUSIONS
  Medication adherence was significantly higher for ARV than for TB medications in this cohort. Short-course treatment regimens for drug-resistant TB with lower pill burden may increase adherence and improve outcomes in XDR-TB/HIV. Programmatic support for dual adherence is critical in the treatment of drug-resistant TB and HIV.
authors.affiliation: *Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, NY; †Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; ‡Centre for Aids Program of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; §Department of Epidemiology, Boston University School of Public Health, Boston, MA; and ‖University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Max R
authors.initials: MR
authors.lastname: OʼDonnell
authors.forename: Allison
authors.initials: A
authors.lastname: Wolf
authors.forename: Lise
authors.initials: L
authors.lastname: Werner
authors.forename: C Robert
authors.initials: CR
authors.lastname: Horsburgh
authors.forename: Nesri
authors.initials: N
authors.lastname: Padayatchi
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D000995:Antitubercular Agents / Q000008:administration & dosage*; D015331:Cohort Studies; D054908:Extensively Drug-Resistant Tuberculosis / Q000188:drug therapy* / Q000276:immunology / Q000382:microbiology; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D015497:HIV-1 / Q000302:isolation & purification*; D006801:Humans; D016015:Logistic Models; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification*; D011446:Prospective Studies; D012959:Socioeconomic Factors; D013019:South Africa; D011795:Surveys and Questionnaires; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents