Standard of Care for MDR-TB Dr Hind Satti Partners In Health Lesotho

Lesotho: Basic Facts Landlocked country located within South Africa (bordering Free State and KwaZulu-Natal) Population 1.8 million 12,275 TB new cases notified in 2009 Over 2000 re treatment cases HIV prevalence rate: 23.2% in 2005 80% of TB cases are HIV positive (NTP 2008)

Lesotho MDR-TB Programme A comprehensive response to MDR-/XDR-TB in Lesotho, established by the MOHSW. International partners include PIH, WHO, FIND, OSI Community-based treatment and care model that includes all 10 districts First patients enrolled in August 2007; 500 patients enrolled to date

National TB Reference Laboratory

Case Detection All HCWs including NTP staff TB/HIV coordinators/Officers at district hospitals Health centre nurses providing HIV/TB care Routine HIV screening of MDR-TB patients, partners, family members Protocol for “medium-risk” and “high-risk” Sputum sent to national TB laboratory Screening of household contacts

Botsabelo MDR-/XDR-TB Hospital

Patient Characteristics Approximately 78% HIV-positive with advanced AIDS-defining conditions Severe malnutrition Multiple failed TB treatment regimens Extensive TB disease Mostly smear-positive

Lesotho vs. rest of the world† *Tomsk, Latvia, Estonia, Peru, Philippines † Nathanson et al. Adverse events in the treatment of multidrug-resistant tuberculosis: results from the DOTS-Plus initiative. Int J Tuberc Lung Dis 2004. 8(11):1382–1384

Infection Control Outpatient Inpatient TB clinics and general outpatient clinics Treatment supporters Family members Inpatient Cross-infection of patients Protection of health workers (TB and HIV)

Social assistance

MDR-TB/HIV 100% HIV testing during the first visit. Early initiation of HARRT for MDRTB/HIV (10-21 days), regardless of CD4 count. Aggressive management of side effects. Home assessment visit before initiation. Household contact screening and testing for TB and HIV.

Role of Treatment Supporter Observe all doses Report side effects Provide injections. Accompany patient for clinical evaluations Screen for TB and HIV in household contacts. Offer psychosocial support to the patient and the family.

Effect of HIV on MDR-TB mortality Seung KJ, Omatayo DB, Keshavjee S, Furin JJ, Farmer PE, Satti H. Early outcomes of MDR-TB treatment in a high HIV-prevalence setting in Southern Africa. PLoS One. 2009 Sep 25;4(9):e7186.

Conclusion Diagnosis and management of MDR-TB in high HIV-prevalence settings is challenging but possible Empiric treatment of MDR-TB is needed to decrease early mortality Side effects are more common and earlier Infection control at all levels: hospital, clinic, community is critical. Community-based MDR-TB/HIV allows for rapid enrollment and closer monitoring of side effects