title: Treating drug-resistant tuberculosis in a low-intensity chronic conflict setting in India.
abstract: BACKGROUND
  The eastern part of India has been affected by an ongoing low-intensity conflict between government forces and armed Maoist groups, known as Naxalites. Since 2006, Médecins Sans Frontières (MSF) has been providing primary health care services in the conflict-affected region along the Andhra Pradesh-Chhattisgarh border. In 2011, treatment for drug-resistant tuberculosis (DR-TB) was included in the services provided. This report aims to describe MSF experiences of providing treatment to DR-TB patients in a mobile primary health care outpatient clinic, in a low-intensity conflict setting in India.
  
  
  METHODS
  A total of thirteen patients were diagnosed with drug-resistant TB (DR-TB) between January 2011 and October 2013. An innovative treatment model was developed which delegated responsibility to non-TB clinicians, including primary-care nurses and nurse-aids who were remotely supported by a TB-specialist from the MSF DR-TB project in Mumbai. Individualised regimens were designed for each patient based on WHO guidelines. Of these 13 patients, 10 patients had an outcome, of whom seven (70%) patients were cured. One patient became lost to follow-up prior to treatment initiation, one patient died prior to starting treatment and one patient refused treatment. Three patients were on-treatment, were clinically improving and were culture-negative at the end of their intensive phase of treatment.
  
  
  RESULTS
  Drug-resistant tuberculosis diagnosis and treatment is a highly specialised and technical subject which requires continued patient follow-up. However, our study demonstrates that it is feasible to manage DR-TB patients in a conflict setting, using a primary-care model with remote expert support. Long-term commitment and sustainability are essential for continued care, even more so in similar conflict settings. Loss to follow-up in patients remains a programmatic challenge and community involvement may play a key role.
  
  
  CONCLUSIONS
  Managing DR-TB in a primary health care programme is feasible in a low-conflict setting with an appropriate treatment model. Ambulatory strategies and standardised treatment regimens should be considered to further simplify treatment delivery and allow for scale-up when needed.
authors.affiliation: Médecins Sans Frontières, Chandni Bungalow, Union Park, Off Carter Road, Khar (W), Mumbai, 400 052 India.
authors.forename: Edward
authors.initials: E
authors.lastname: Armstrong
authors.affiliation: Médecins Sans Frontières, Chandni Bungalow, Union Park, Off Carter Road, Khar (W), Mumbai, 400 052 India.
authors.forename: Mrinalini
authors.initials: M
authors.lastname: Das
authors.affiliation: Médecins Sans Frontières, Chandni Bungalow, Union Park, Off Carter Road, Khar (W), Mumbai, 400 052 India.
authors.forename: Homa
authors.initials: H
authors.lastname: Mansoor
authors.affiliation: District TB Control Office (RNTCP), Khammam District, Andhra Pradesh India.
authors.forename: Ramesh B
authors.initials: RB
authors.lastname: Babu
authors.affiliation: Médecins Sans Frontières, Chandni Bungalow, Union Park, Off Carter Road, Khar (W), Mumbai, 400 052 India.
authors.forename: Petros
authors.initials: P
authors.lastname: Isaakidis
keywords: Internally displaced populations; Mobile clinic; Operational research; Resource-limited settings