Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South Africa
Background. Progressive interventions have recently improved programmatic outcomes in drug-resistant tuberculosis (DR-TB) care in South Africa (SA). Amidst these, a shorter regimen was introduced in 2017 with weak evidence, and has shown mixed results. Outcomes still fall short of national targ...
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South African Medical Association
2023-11-01
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| Series: | South African Medical Journal |
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| Online Access: | https://samajournals.co.za/index.php/samj/article/view/497 |
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| author | J-D K Lotz J Porter H Conradie T Boyles B Gaunt S Dimanda D Cort |
| author_facet | J-D K Lotz J Porter H Conradie T Boyles B Gaunt S Dimanda D Cort |
| author_sort | J-D K Lotz |
| collection | DOAJ |
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Background. Progressive interventions have recently improved programmatic outcomes in drug-resistant tuberculosis (DR-TB) care in South Africa (SA). Amidst these, a shorter regimen was introduced in 2017 with weak evidence, and has shown mixed results. Outcomes still fall short of national targets, and the coronavirus disease 2019 pandemic has undermined progress to date.
Objectives. To describe the outcomes of participants treated for DR-TB using a shorter, compared with a longer, regimen in a deeply rural SA setting, and to explore other factors affecting these outcomes.
Methods. This retrospective cohort study describes outcomes in short and long DR-TB treatment regimens, over 5 years, at two rural treatment sites in SA. Characteristics were analysed for outcome correlates using multivariable logistic regression models.
Results. Of 282 treatment episodes, 62% were successful, with higher success in shorter (69%) compared with longer regimens (58%). Mortality was approximately 21% in both groups. Characteristics included high proportions of HIV co-infection (61%). Injectables (adjusted odds ratio (aOR) 3.00, 95% confidence interval (CI) 1.48 - 6.09), bedaquiline (aOR 3.16, 95% CI 1.36 - 7.35), increasing age (aOR 0.97, 95% CI 0.95 - 0.99) and HIV viraemia defined as final HIV-RNA viral load >1 000 copies/mL (aOR 0.16, 95% CI 0.07 - 0.37) were all significantly and independently associated with treatment success. Injectables (aOR 0.22, 95% CI 0.08 - 0.57), bedaquiline (aOR 0.05, 95% CI 0.01 - 0.19), increasing age (aOR 1.09, 95% CI 1.05 - 1.13), extra-pulmonary TB (aOR 8.15, 95% CI 1.62 - 41.03) and HIV viraemia (aOR 9.20, 95% CI 3.22 - 26.24) were all significantly and independently associated with mortality.
Conclusion. In a rural context, treating DR-TB amid limited resources and a high burden of HIV co-infection, we found that after considering controls, a short regimen was no different to a longer regimen in terms of success or mortality. Therefore, by alleviating burdens on multiple stakeholders, a short regimen is likely to be favourable for rural patients, clinicians, and healthcare systems. Besides other previously described correlates of outcomes, HIV viraemia emerged as a novel marker for reliably predicting poor outcomes in DR-TB with HIV co-infection, and a pragmatic target for intervention.
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| format | Article |
| id | doaj-art-60f8f40025da4439b2a446894df101dd |
| institution | Kabale University |
| issn | 0256-9574 2078-5135 |
| language | English |
| publishDate | 2023-11-01 |
| publisher | South African Medical Association |
| record_format | Article |
| series | South African Medical Journal |
| spelling | doaj-art-60f8f40025da4439b2a446894df101dd2025-02-10T12:26:42ZengSouth African Medical AssociationSouth African Medical Journal0256-95742078-51352023-11-011131110.7196/SAMJ.2023.v113i11.497Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South AfricaJ-D K Lotz0https://orcid.org/0000-0003-4632-6076J Porter1H Conradie2T Boyles3https://orcid.org/0000-0002-5676-8081B Gaunt4https://orcid.org/0000-0001-7589-6145S Dimanda5D Cort6https://orcid.org/0000-0003-0554-9783Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha, South Africa, Madwaleni District Hospital, Elliotdale, South AfricaDepartment of Family Medicine and Rural Health, Walter Sisulu University, Mthatha, South Africa, Division of Family Medicine, Department of Family, Community, and Emergency Care, University of Cape Town, South Africa, False Bay District Hospital, Cape Town, South AfricaDepartment of Family Medicine and Primary Care, Stellenbosch University, Cape Town, South AfricaRight to Care, Centurion, South Africa, Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa, London School of Hygiene and Tropical Medicine, London, United KingdomZithulele District Hospital, Coffee Bay, South AfricaMadwaleni District Hospital, Elliotdale, South AfricaDepartment of Sociology, University of Massachusetts, Amherst, USA Background. Progressive interventions have recently improved programmatic outcomes in drug-resistant tuberculosis (DR-TB) care in South Africa (SA). Amidst these, a shorter regimen was introduced in 2017 with weak evidence, and has shown mixed results. Outcomes still fall short of national targets, and the coronavirus disease 2019 pandemic has undermined progress to date. Objectives. To describe the outcomes of participants treated for DR-TB using a shorter, compared with a longer, regimen in a deeply rural SA setting, and to explore other factors affecting these outcomes. Methods. This retrospective cohort study describes outcomes in short and long DR-TB treatment regimens, over 5 years, at two rural treatment sites in SA. Characteristics were analysed for outcome correlates using multivariable logistic regression models. Results. Of 282 treatment episodes, 62% were successful, with higher success in shorter (69%) compared with longer regimens (58%). Mortality was approximately 21% in both groups. Characteristics included high proportions of HIV co-infection (61%). Injectables (adjusted odds ratio (aOR) 3.00, 95% confidence interval (CI) 1.48 - 6.09), bedaquiline (aOR 3.16, 95% CI 1.36 - 7.35), increasing age (aOR 0.97, 95% CI 0.95 - 0.99) and HIV viraemia defined as final HIV-RNA viral load >1 000 copies/mL (aOR 0.16, 95% CI 0.07 - 0.37) were all significantly and independently associated with treatment success. Injectables (aOR 0.22, 95% CI 0.08 - 0.57), bedaquiline (aOR 0.05, 95% CI 0.01 - 0.19), increasing age (aOR 1.09, 95% CI 1.05 - 1.13), extra-pulmonary TB (aOR 8.15, 95% CI 1.62 - 41.03) and HIV viraemia (aOR 9.20, 95% CI 3.22 - 26.24) were all significantly and independently associated with mortality. Conclusion. In a rural context, treating DR-TB amid limited resources and a high burden of HIV co-infection, we found that after considering controls, a short regimen was no different to a longer regimen in terms of success or mortality. Therefore, by alleviating burdens on multiple stakeholders, a short regimen is likely to be favourable for rural patients, clinicians, and healthcare systems. Besides other previously described correlates of outcomes, HIV viraemia emerged as a novel marker for reliably predicting poor outcomes in DR-TB with HIV co-infection, and a pragmatic target for intervention. https://samajournals.co.za/index.php/samj/article/view/497tuberculosisshort regimenruralSouth Africadrug-resistantDR-TB |
| spellingShingle | J-D K Lotz J Porter H Conradie T Boyles B Gaunt S Dimanda D Cort Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South Africa South African Medical Journal tuberculosis short regimen rural South Africa drug-resistant DR-TB |
| title | Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South Africa |
| title_full | Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South Africa |
| title_fullStr | Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South Africa |
| title_full_unstemmed | Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South Africa |
| title_short | Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South Africa |
| title_sort | treating drug resistant tuberculosis in an era of shorter regimens insights from rural south africa |
| topic | tuberculosis short regimen rural South Africa drug-resistant DR-TB |
| url | https://samajournals.co.za/index.php/samj/article/view/497 |
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