title: Alarming levels of drug-resistant tuberculosis in HIV-infected patients in metropolitan Mumbai, India.
abstract: BACKGROUND
  Drug-resistant tuberculosis (DR-TB) is a looming threat to tuberculosis control in India. However, no countrywide prevalence data are available. The burden of DR-TB in HIV-co-infected patients is likewise unknown. Undiagnosed and untreated DR-TB among HIV-infected patients is a major cause of mortality and morbidity. We aimed to assess the prevalence of DR-TB (defined as resistance to any anti-TB drug) in patients attending public antiretroviral treatment (ART) centers in greater metropolitan Mumbai, India.
  
  
  METHODS
  A cross-sectional survey was conducted among adults and children ART-center attendees. Smear microscopy, culture and drug-susceptibility-testing (DST) against all first and second-line TB-drugs using phenotypic liquid culture (MGIT) were conducted on all presumptive tuberculosis patients. Analyses were performed to determine DR-TB prevalence and resistance patterns separately for new and previously treated, culture-positive TB-cases.
  
  
  RESULTS
  Between March 2013 and January 2014, ART-center attendees were screened during 14135 visits, of whom 1724 had presumptive TB. Of 1724 attendees, 72 (4%) were smear-positive and 202 (12%) had a positive culture for Mycobacterium tuberculosis. Overall DR-TB was diagnosed in 68 (34%, 95% CI: 27%-40%) TB-patients. The proportions of DR-TB were 25% (29/114) and 44% (39/88) among new and previously treated cases respectively. The patterns of DR-TB were: 21% mono-resistant, 12% poly-resistant, 38% multidrug-resistant (MDR-TB), 21% pre-extensively-drug-resistant (MDR-TB plus resistance to either a fluoroquinolone or second-line injectable), 6% extensively drug-resistant (XDR-TB) and 2% extremely drug-resistant TB (XDR-TB plus resistance to any group-IV/V drug). Only previous history of TB was significantly associated with the diagnosis of DR-TB in multivariate models.
  
  
  CONCLUSIONS
  The burden of DR-TB among HIV-infected patients attending public ART-centers in Mumbai was alarmingly high, likely representing ongoing transmission in the community and health facilities. These data highlight the need to promptly diagnose drug-resistance among all HIV-infected patients by systematically offering access to first and second-line DST to all patients with 'presumptive TB' rather than 'presumptive DR-TB' and tailor the treatment regimen based on the resistance patterns.
authors.affiliation: Médecins Sans Frontières, Mumbai, India.
authors.forename: Petros
authors.initials: P
authors.lastname: Isaakidis
authors.affiliation: Médecins Sans Frontières, Mumbai, India.
authors.forename: Mrinalini
authors.initials: M
authors.lastname: Das
authors.affiliation: International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, New Delhi, India.
authors.forename: Ajay M V
authors.initials: AM
authors.lastname: Kumar
authors.affiliation: Médecins Sans Frontières, Mumbai, India.
authors.forename: Christopher
authors.initials: C
authors.lastname: Peskett
authors.affiliation: City TB Office, Bawala Wadi, Chinckpokli, Mumbai, India.
authors.forename: Minni
authors.initials: M
authors.lastname: Khetarpal
authors.affiliation: Brihanmumbai Municipal Corporation, Mumbai, India.
authors.forename: Arun
authors.initials: A
authors.lastname: Bamne
authors.affiliation: Mumbai District AIDS Control Society (MDACS), Mumbai, India.
authors.forename: Balkrishna
authors.initials: B
authors.lastname: Adsul
authors.affiliation: Pediatric Centre of Excellence for HIV Care, L.T.M. Medical College & General Hospital, Sion, Mumbai, India.
authors.forename: Mamta
authors.initials: M
authors.lastname: Manglani
authors.affiliation: Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi, India.
authors.forename: Kuldeep Singh
authors.initials: KS
authors.lastname: Sachdeva
authors.affiliation: World Health Organisation - Country Office for India, New Delhi, India.
authors.forename: Malik
authors.initials: M
authors.lastname: Parmar
authors.affiliation: Department of AIDS Control, National AIDS Control Organisation, New Delhi, India.
authors.forename: Avinash
authors.initials: A
authors.lastname: Kanchar
authors.affiliation: Department of AIDS Control, National AIDS Control Organisation, New Delhi, India.
authors.forename: B B
authors.initials: BB
authors.lastname: Rewari
authors.affiliation: MGM Institute of Health Sciences, Navi Mumbai, India.
authors.forename: Alaka
authors.initials: A
authors.lastname: Deshpande
authors.affiliation: P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India.
authors.forename: Camilla
authors.initials: C
authors.lastname: Rodrigues
authors.affiliation: P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India.
authors.forename: Anjali
authors.initials: A
authors.lastname: Shetty
authors.affiliation: Médecins Sans Frontières, Mumbai, India.
authors.forename: Lorraine
authors.initials: L
authors.lastname: Rebello
authors.affiliation: Southern Africa Medical Unit (SAMU), Médecins Sans Frontières, Cape Town, South Africa.
authors.forename: Peter
authors.initials: P
authors.lastname: Saranchuk
mesh_terms: D000293:Adolescent; D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use; D044466:Asian People; D002648:Child; D003430:Cross-Sectional Studies; D003710:Demography; D004359:Drug Therapy, Combination; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000175:diagnosis*; D006801:Humans; D007194:India; D008297:Male; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification*; D015995:Prevalence; D014376:Tuberculosis / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology*; D018088:Tuberculosis, Multidrug-Resistant / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology
chemical_list: D000995:Antitubercular Agents