1. Daniel Meressa, M.D. Global Health Committee St. Peter’s Hospital
HIV-MDR TB Treatment in Ethiopia: A Successful Hospital and Community-based Treatment Model since 2009
Daniel Meressa, M.D.
Global Health Committee
St. Peter’s Hospital

2. Introduction: TB in Ethiopia
Ethiopia ranks 8th among 22 high-TB burden countries and 3rd in Africa
Ethiopia ranks 15th out of the 27 global MDR-TB priority countries:
An Estimated 5200 MDRTB cases emerged in 2008
Adult HIV prevalence 2.4%
TB/HIV co-infection rate 17%
Ethiopian Anti-TB Drug-resistance Surveillance (2005):
Proportion of MDR-TB 1.6% and 11.8% among new and re-treatment cases respectively.
There were 273 DST confirmed MDR-TB patients in 2008 (EHNRI)

3. Introduction: MDR-TB Treatment in Ethiopia
MDRTB Treatment initiated in February 2009: Partnership FMOH & Global Health Committee
Approved by the Green Light Committee
Treatment Model of care:
Hospitalization: Initial cohort of patients enrolled as inpatients during the first months of treatment
Community-based care: Outpatient [Home initiation of treatment] currently account for nearly ½ enrollments
Overall 80% of patients are being managed as outpatients
Multidisciplinary: includes nutritional & psychosocial support
Standardized regimens are used (5 drugs) – with tailoring based on DST and treatment evolution

4. Background: Ethiopian MDR-TB Treatment Program
As of November 2011:
336 patient s enrolled at 2 sites: Addis & Gondar
Median age: 27 years
46% males & 54% females
Co-morbidities (non-HIV):
4.9% with Diabetes
4.9% with Cor pulmonale
Low BMI: median 18.5
Advanced disease:
68.6% with bilateral cavitary disease
Source: PC : A Successful Model for MDR-TB treatment and Scale-up in Ethiopia with a community-based program, presented 41st IUATLD Conference, Lille, France, October 2011

5. Methods
Retrospective review and analysis of the medical records of HIV-MDRTB co-infected patients enrolled in the MDR-TB Treatment Program
February 1, 2009 through June 1, 2011

6. Results 46 HIV co-infected patients, 21.1% of total cohort
Baseline Characteristics:
Median age: (range 9-55)
Median BMI: ( )
Site of Disease:
Pulmonary only: 40 (86.9%)
Extra-pulmonary only: 1 (2.1%)
Both Pulmonary and Extra-pulmonary: 10.8%
All 46 pts (100%) diagnosed with HIV prior to initiation of MDR-TB treatment

7. Results Contacts of MDRTB: 2 Patients (4.3%)
Median number of prior TB treatments: 2 (range 1-4)
Median number of drugs isolates are resistant to: 4 ( range 2-6)
XDR-TB suspects: 3 Patients
MDRTB treatment regimens used (5):
PZA/Capreo/Levoflox/Ethio/Cycloserine in 35
PZA/Amik/Levoflox/Ethio/Cycloserine in 8
PZA/Capreo/Moxi/Ethio/Cycloserine/PAS/Amx-clv/CLR in 1
PZA/Capreo/Moxi/Cycloserine/PAS in 1
PZA/Amik/Levoflox/Ethio/Cycloserine/PAS in 1
Median Duration of the Intensive phase: 8 months (range 6-18)

8. Results: HIV-related Initial CD4 count at initiation:
247 (range )
Follow-up CD4 counts during treatment:
329 (range )
Cotrimoxazole use: 91.3% patients
Treatment with Antiviral Therapy (HAART) for all pts regardless of CD4
42 pts on ARVs upon enrollment in program
3 pts began ARVs during MDRTB treatment
1 pt has declined ARVs
Opportunistic Infections during MDR treatment:
CNS toxoplasmosis = (3) 6.5%
Bacterial pneumonia = (6) 13%
Oral Candidiasis = (8) 17.3 %

9. Results: Co-morbidities

10. Results: HIV-related
Initial patients more likely to be on D4T-containing regimens
2 patients requiring switch
Shift to non-D4T regimens:
several patients awaiting a switch once confirmed to be virologically suppressed

11. Results: Adverse Effects

12. Results: Interim Treatment Outcomes

13. Conclusions
Management MDR-TB /HIV co-infection remains to be a big challenge
Despite advanced TB disease, severe malnutrition and additional co-morbidities, HIV-MDRTB patients can achieve promising outcomes
Access to ART and close clinical management of MDRTB and HIV complications is essential
Rapid diagnostic testing and early access to MDRTB and HIV care is essential to capture a larger segment of the co-infected population
Adverse effects are common in co-infected patients. Close surveillance and careful management is required
Optimal co-treatment regimens need to be defined
HIV-MDRTB clinical and programmatic management can be integrated and successfully managed in the Ethiopian context

14. Acknowledgments Federal Ministry of Health & St. Peter’s Hospital
Anne Goldfeld, GHC & Harvard Medical School ,GHC Staffs
Gondar University Hospital
USAID/TB CARE I
MSH/HEAL TB
CDC/ITECH/ICAP/JHU/UCSD
EHNRI/FIND
Prof. Getachew Aderaye
Jolie-Pitt Foundation
Annenberg Foundation
Eli-Lilly and Co and its MDR Partnership and Jacobus