1. 4 th National Anti-tuberculosis Drug Resistance Survey Botswana, 2007

2. Objectives Perform drug resistance survey among culture positive TB patients –Identify trends of 1 st -line drug resistance compared to previous surveys Perform 2 nd line drug testing to identify XDR-TB Determine prevalence of HIV infection among TB patients Evaluate whether HIV infection is a risk factor for MDR TB

3. Background Multidrug-resistant TB (MDR TB) –Resistance to at least isoniazid and rifampin Extensively drug-resistant TB (XDR TB) –MDR TB plus resistance to: a fluoroquinolone AND one or more injectable 2 nd line drug (amikacin, capreomycin, kanamycin)

4. Background (3) Concern for increasing anti-TB drug resistance Previous 3 national drug resistance surveys of NEW cases: –1995/96: 3.7% any resistance/ 0.2% MDR TB –1999: 6.3% any resistance/ 0.5% MDR TB –2002: 10.4% any resistance/ 0.8% MDR TB XDR TB recently identified in South Africa High HIV prevalence –2005: 33.4% of women receiving antenatal testing are HIV+ in Botswana

5. Methods May – October 2007 To NTRL All sputum specimens from NEW smear-positive cases All retreatment cases –Culture on Lowenstein Jensen media –1st line drug susceptibility testing at NTRL –2 nd line drug susceptibility testing at SNRL in South Africa Participating sites: all facilities offering TB treatment (inpatient and outpatient)

6. HIV Testing To determine HIV prevalence: –Unlinked anonymous HIV testing of all sputum specimens using Oraquick Unique ID (UID) assigned by 3 rd party algorithm To evaluate HIV as risk factor for MDR TB –De-identified DST results assigned same UID by 3 rd party algorithm and merged with unlinked anonymous HIV results

7. Expected Results Primary –Identify trends in resistance to anti-TB drugs Secondary –Identify trends in MDR TB –Identify XDR TB and establish baseline for analysis of future trends –Determine HIV prevalence among TB patients –Determine if HIV infection is risk factor for MDR-TB –Identify trends in rifampin mono-resistance –Determine rates of high-level and low-level isoniazid resistance

8. TBC Role To assist with and facilitate the survey by –Follow-up calls to clinics and labs to be sure they are submitting specimens in a timely fashion –Working with survey coordinator at the NTRL to be sure that the proper number of specimens are received –Working with NTRL to follow-up on missing data –Work with NTRL and Clinic Matrons to ensure that

9. Next Steps Study Investigators will develop SOPs (standard operating procedures) for study Investigators will visit each district to train for study in April and May Data collection to commence in May