Achieving high treatment success for multidrug-resistant TB in Africa: initiation and scale-up of MDR TB care in Ethiopia--an observational cohort study.
BACKGROUND
In Africa, fewer than half of patients receiving therapy for multidrug-resistant TB (MDR TB) are successfully treated, with poor outcomes reported for HIV-coinfected patients.


METHODS
A standardised second-line drug (SLD) regimen was used in a non-governmental organisation-Ministry of Health (NGO-MOH) collaborative community and hospital-based programme in Ethiopia that included intensive side effect monitoring, adherence strategies and nutritional supplementation. Clinical outcomes for patients with at least 24 months of follow-up were reviewed and predictors of treatment failure or death were evaluated by Cox proportional hazards models.


RESULTS
From February 2009 to December 2014, 1044 patients were initiated on SLD. 612 patients with confirmed or presumed MDR TB had ≥ 24 months of follow-up, 551 (90.0%) were confirmed and 61 (10.0%) were suspected MDR TB cases. 603 (98.5%) had prior TB treatment, 133 (21.7%) were HIV coinfected and median body mass index (BMI) was 16.6. Composite treatment success was 78.6% with 396 (64.7%) cured, 85 (13.9%) who completed treatment, 10 (1.6%) who failed, 85 (13.9%) who died and 36 (5.9%) who were lost to follow-up. HIV coinfection (adjusted HR (AHR): 2.60, p<0.001), BMI (AHR 0.88/kg/m(2), p=0.006) and cor pulmonale (AHR 3.61, p=0.003) and confirmed MDR TB (AHR 0.50, p=0.026) were predictive of treatment failure or death.


CONCLUSIONS
We report from Ethiopia the highest MDR TB treatment success outcomes so far achieved in Africa, in a setting with severe resource constraints and patients with advanced disease. Intensive treatment of adverse effects, nutritional supplementation, adherence interventions and NGO-MOH collaboration were key strategies contributing to success. We argue these approaches should be routinely incorporated into programmes.
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia St. Peter's Tuberculosis Specialized Hospital, Addis Ababa, Ethiopia.
Daniel
D
Meressa
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.
Rocío M
RM
Hurtado
Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.
Jason R
JR
Andrews
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia University of Gondar Hospital, Gondar, Ethiopia.
Ermias
E
Diro
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia.
Kassim
K
Abato
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia.
Tewodros
T
Daniel
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Current affiliation: Pulmonary and Critical Care Medicine Division, University of Rochester Medical Center, Rochester, New York, USA.
Paritosh
P
Prasad
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Current affiliation: Pediatrics Department, University of Rochester Medical Center, Rochester, New York, USA.
Rebekah
R
Prasad
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia.
Bekele
B
Fekade
St. Peter's Tuberculosis Specialized Hospital, Addis Ababa, Ethiopia.
Yared
Y
Tedla
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia University of Gondar Hospital, Gondar, Ethiopia.
Hanan
H
Yusuf
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia.
Melaku
M
Tadesse
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia University of Gondar Hospital, Gondar, Ethiopia.
Dawit
D
Tefera
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia.
Abraham
A
Ashenafi
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia.
Girma
G
Desta
Hallelujah Clinic, Addis Ababa, Ethiopia.
Getachew
G
Aderaye
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.
Kristian
K
Olson
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Cambodian Health Committee, Phnom Penh, Cambodia.
Sok
S
Thim
Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Cambodian Health Committee, Phnom Penh, Cambodia Program in Cellular and Molecular Medicine, Children's Hospital Boston, Boston, Massachusetts, USA.
Anne E
AE
Goldfeld
D000328:Adult; D060085:Coinfection; D005002:Ethiopia; D005260:Female; D015658:HIV Infections / Q000453:epidemiology; D006801:Humans; D008297:Male; D055118:Medication Adherence; D016016:Proportional Hazards Models; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy / Q000453:epidemiology / Q000401:mortality / Q000628:therapy*; D055815:Young Adult
Tuberculosis