title: Loss from treatment for drug resistant tuberculosis: risk factors and patient outcomes in a community-based program in Khayelitsha, South Africa.
abstract: BACKGROUND
  A community based drug resistant tuberculosis (DR-TB) program has been incrementally implemented in Khayelitsha, a high HIV and TB burden community in South Africa. We investigated loss from treatment (LFT), and post treatment outcomes of DR-TB patients in this setting.
  
  
  METHODS
  LFT, defined as interruption of treatment for ≥2 consecutive months was assessed among patients initiating DR-TB treatment for the first time between January 2009 and July 2011. Patients were traced through routine data sources to identify those who subsequently restarted treatment and those who died. Additional information on patient status and survival after LTF was obtained from community DR-TB counselors and from the national death registry. Post treatment outcomes were observed until July 2013.
  
  
  RESULTS
  Among 452 patients initiating treatment for the first time within the given period, 30% (136) were LFT, with 67% retention at 18 months. Treatment was restarted in 27 (20%) patients, with additional resistance recorded in 2/25 (8%), excluding two with presumed DR-TB. Overall, 34 (25%) patients died, including 11 who restarted treatment. Males and those in the age category 15-25 years had a greater hazard of LFT; HR 1.93 (95% CI 1.35-2.75), and 2.43 (95% CI 1.52-3.88) respectively. Older age (>35 years) was associated with a greater hazard of death; HR 3.74 (1.13- 12.37) post treatment. Overall two-year survival was 62%. It was lower (45%) in older patients, and was 92% among those who received >12 months treatment.
  
  
  CONCLUSIONS
  LFT was high, occurred throughout the treatment period and was particularly high among males and those aged 15-25 years. Overall long term survival was poor. High rates of LFT should however not preclude scale up of community based care given its impact in increasing access to treatment. Further research is needed to support retention of DR-TB patients on treatment, even within community based treatment programs.
authors.affiliation: Médecins sans Frontières (MSF, Doctors without Borders), Khayelitsha, Cape Town, South Africa; Human Sciences Research Council, HIV/AIDS, STIs and TB programme, Cape Town, South Africa.
authors.forename: Sizulu
authors.initials: S
authors.lastname: Moyo
authors.affiliation: Department of Medical Microbiology, University of Cape Town, Cape Town, South Africa.
authors.forename: Helen S
authors.initials: HS
authors.lastname: Cox
authors.affiliation: Médecins sans Frontières (MSF, Doctors without Borders), Khayelitsha, Cape Town, South Africa.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hughes
authors.affiliation: Médecins sans Frontières (MSF, Doctors without Borders), Khayelitsha, Cape Town, South Africa.
authors.forename: Johnny
authors.initials: J
authors.lastname: Daniels
authors.affiliation: Médecins sans Frontières (MSF, Doctors without Borders), Khayelitsha, Cape Town, South Africa.
authors.forename: Leigh
authors.initials: L
authors.lastname: Synman
authors.affiliation: City of Cape Town Department of Health, Cape Town, South Africa.
authors.forename: Virginia
authors.initials: V
authors.lastname: De Azevedo
authors.affiliation: Médecins sans Frontières (MSF, Doctors without Borders), Khayelitsha, Cape Town, South Africa.
authors.forename: Amir
authors.initials: A
authors.lastname: Shroufi
authors.affiliation: Médecins sans Frontières (MSF, Doctors without Borders), Khayelitsha, Cape Town, South Africa.
authors.forename: Vivian
authors.initials: V
authors.lastname: Cox
authors.affiliation: Médecins sans Frontières (MSF, Doctors without Borders), Khayelitsha, Cape Town, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.
authors.forename: Gilles
authors.initials: G
authors.lastname: van Cutsem
mesh_terms: D000293:Adolescent; D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use; D005260:Female; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D012111:Residence Characteristics; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy* / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000995:Antitubercular Agents