title: Community-based care vs. centralised hospitalisation for MDR-TB patients, KwaZulu-Natal, South Africa.
abstract: METHODS
  KwaZulu-Natal, South Africa, a predominantly rural province with a high burden of tuberculosis (TB), multidrug-resistant TB (MDR-TB) and human immunodeficiency virus (HIV) infection.
  
  
  OBJECTIVE
  To determine the most effective care model by comparing MDR-TB treatment outcomes at community-based sites with traditional care at a central, specialised hospital.
  
  
  METHODS
  A non-randomised observational prospective cohort study comparing community-based and centralised care. Patients at community-based sites were closer to home and had easier access to care, and home-based care was available from treatment initiation.
  
  
  RESULTS
  Four community-based sites treated 736 patients, while 813 were treated at the centralised hospital (total = 1549 patients). Overall, 75% were HIV co-infected (community: 76% vs. hospitalised: 73%, P = 0.45) and 86% received antiretroviral therapy (community: 91% vs. hospitalised: 82%, P = 0.22). On multivariate analysis, MDR-TB patients were more likely to have a successful treatment outcome if they were treated at a community-based site (adjusted OR 1.43, P = 0.01). However, outcomes at the four community-based sites were heterogeneous, with Site 1 demonstrating that home-based care was associated with an increased treatment success of 72% compared with success rates of 52-60% at the other three sites.
  
  
  CONCLUSIONS
  Community-based care for MDR-TB patients was more effective than care in a central, specialised hospital. Home-based care further increased treatment success.
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
authors.forename: M
authors.initials: M
authors.lastname: Loveday
authors.affiliation: TB and HIV Investigative Network (Think), Durban, South Africa.
authors.forename: K
authors.initials: K
authors.lastname: Wallengren
authors.affiliation: Department of Medicine, Montefiore Medical Center & Albert Einstein College of Medicine, New York, New York, USA.
authors.forename: J
authors.initials: J
authors.lastname: Brust
authors.affiliation: Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: J
authors.initials: J
authors.lastname: Roberts
authors.affiliation: Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: A
authors.initials: A
authors.lastname: Voce
authors.affiliation: KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa.
authors.forename: B
authors.initials: B
authors.lastname: Margot
authors.affiliation: KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa.
authors.forename: J
authors.initials: J
authors.lastname: Ngozo
authors.affiliation: King Dinuzulu Hospital, Durban, South Africa.
authors.forename: I
authors.initials: I
authors.lastname: Master
authors.affiliation: Harvard University School of Medicine, Boston, Massachusetts, USA.
authors.forename: G
authors.initials: G
authors.lastname: Cassell
authors.affiliation: Centre for the AIDS Programme of Research in South Africa, Durban, South Africa.
authors.forename: N
authors.initials: N
authors.lastname: Padayatchi
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D003153:Community Health Services / Q000458:organization & administration*; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy; D006297:Health Services Accessibility; D006699:Home Care Services / Q000458:organization & administration; D006760:Hospitalization; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D011446:Prospective Studies; D013019:South Africa; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy*
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents