Ambulatory Multi-Drug Resistant Tuberculosis Treatment Outcomes in a Cohort of HIV-Infected Patients in a Slum Setting in Mumbai, India

Background: India carries one quarter of the global burden of multi-drug resistant TB (MDR-TB) and has an estimated 2.5 million people living with HIV. Despite this reality, provision of treatment for MDR-TB is extremely limited, particularly for HIV-infected individuals. Médecins Sans Frontières (MSF) has been treating HIV-infected MDR-TB patients in Mumbai since May 2007. This is the first report of treatment outcomes among HIV-infected MDR-TB patients in India. Methods: HIV-infected patients with suspected MDR-TB were referred to the MSF-clinic by public Antiretroviral Therapy (ART) Centers or by a network of community non-governmental organizations. Patients were initiated on either empiric or individualized second-line TB-treatment as per WHO recommendations. MDR-TB treatment was given on an ambulatory basis and under directly observed therapy using a decentralized network of providers. Patients not already receiving ART were started on treatment within two months of initiating MDR-TB treatment. Results: Between May 2007 and May 2011, 71 HIV-infected patients were suspected to have MDR-TB, and 58 were initiated on treatment. MDR-TB was confirmed in 45 (78%), of which 18 (40%) were resistant to ofloxacin. Final treatment outcomes were available for 23 patients; 11 (48%) were successfully treated, 4 (17%) died, 6 (26%) defaulted, and 2 (9%) failed treatment. Overall, among 58 patients on treatment, 13 (22%) were successfully treated, 13 (22%) died, 7 (12%) defaulted, two (3%) failed treatment, and 23 (40%) were alive and still on treatment at the end of the observation period. Twenty-six patients (45%) experienced moderate to severe adverse events, requiring modification of the regimen in 12 (20%). Overall, 20 (28%) of the 71 patients with MDR-TB died, including 7 not initiated on treatment. Conclusions: Despite high fluoroquinolone resistance and extensive prior second-line treatment, encouraging results are being achieved in an ambulatory MDR-T- program in a slum setting in India. Rapid scale-up of both ART and second-line treatment for MDR-TB is needed to ensure survival of co-infected patients and mitigate this growing epidemic.</br

Characteristics, immunological response & treatment outcomes of HIV-2 compared with HIV-1 & dual infections (HIV 1/ 2) in Mumbai

Information available on HIV-2 and dual infection (HIV-1/2) is limited. This study was carried out among HIV positive individuals in an urban referral clinic in Khar, Mumbai, India, to report on relative proportions of HIV-1, HIV-2 and HIV-1/2 and baseline characteristics, response to and outcomes on antiretroviral treatment (ART)

Tracing patients on antiretroviral treatment lost-to-follow-up in an urban slum in India

Aim: This article describes a cooperative initiative between an HIV-clinic and non-government organization network providing lost-to-follow-up tracing and delayed appointment follow-up of patients on antiretroviral treatment. Background: Loss-to-follow-up among patients on antiretroviral treatment is a major challenge in resource-constrained settings. A model of cooperation between a Médecins Sans Frontières HIV-clinic and a non-governmental-organization network was piloted in a Mumbai slum. A steady decline in delayed appointments and loss-to-follow-up was observed over 4 years. Design: Mixed method study. Methods: A study conducted in January 2011 explored potential reasons for declining loss-to-follow-up-rates. A retrospective, quantitative analysis of patient data was undertaken complemented by 22 semi-structured interviews, four focus-group discussions to explore patients’ and providers’ perceptions of tracing activities. Results/findings: The clinic loss-to-follow-up-rate has steadily declined from mid-2008–2011. Thirty-eight (4•6%) of 819 patients registered during the period were lost-to-follow-up with most lost during the first year. Rates of loss-to-follow-up between 0•3–2•4% were observed over the last 2 years. Phoning the day before an appointment was perceived as the most useful intervention to avoid missing appointments. The analysis revealed a widespread fear of forced disclosure by patients during home visits.Conclusions: The low loss-to-follow-up-rate cannot be attributed to the network tracing activities alone. Phoning before appointments may result in fewer delayed appointments and prevent loss-to-follow-up. Home visits should be a last resort method of patient tracing because of the risk of HIV-status disclosure and the opportunity of discrimination from family and neighbours

HIV, multidrug-resistant TB and depressive symptoms: when three conditions collide

Background: Management of multidrug-resistant TB (MDR-TB) patients co-infected with human immunodeficiency virus (HIV) is highly challenging. Such patients are subject to long and potentially toxic treatments and may develop a number of different psychiatric illnesses such as anxiety and depressive disorders. A mental health assessment before MDR-TB treatment initiation may assist in early diagnosis and better management of psychiatric illnesses in patients already having two stigmatising and debilitating diseases. Objective: To address limited evidence on the baseline psychiatric conditions of HIV-infected MDR-TB patients, we aimed to document the levels of depressive symptoms at baseline, and any alteration following individualized clinical and psychological support during MDR-TB therapy, using the Patient Health Questionnaire-9 (PHQ-9) tool, among HIV-infected patients. Design: This was a retrospective review of the medical records of an adult (aged >15 years) HIV/MDR-TB cohort registered for care during the period of August 2012 through to March 2014. Results: A total of 45 HIV/MDR-TB patients underwent baseline assessment using the PHQ-9 tool, and seven (16%) were found to have depressive symptoms. Of these, four patients had moderate to severe depressive symptoms. Individualized psychological and clinical support was administered to these patients. Reassessments were carried out for all patients after 3 months of follow-up, except one, who died during the period. Among these 44 patients, three with baseline depressive symptoms still had depressive symptoms. However, improvements were observed in all but one after 3 months of follow-up. Conclusion: Psychiatric illnesses, including depressive symptoms, during MDR-TB treatment demand attention. Routine administration of baseline mental health assessments by trained staff has the potential to assist in determining appropriate measures for the management of depressive symptoms during MDR-TB treatment, and help in improving overall treatment outcomes. We recommend regular monitoring of mental health status by trained counsellors or clinical staff, using simple, validated and cost-effective tools

Definitions, grading, monitoring and management of adverse events in MSF HIV/MDR-TB program, Mumbai, India.

<p>IP: intensive phase, CP: continuation phase, D4T  =  stavudine; Cs  =  cycloserine; INH = isoniazide, E  =  ethambutol; Ethio  =  ethionamide; AZT  =  azidothymidine; TDF  =  tenofovir; EFV  =  efavirenz; FQs  =  fluoroquinolones; LPV+lopinavir; NVP  =  nevirapine; P  =  pyrazinamide; PAS  =  para-aminosalicylic acid; ALT  =  alanine aminotransferase; ARV  =  antiretroviral; S  =  streptomycin; K  =  kanamycin; Cm  =  capreomycin.</p

Adverse drug reactions in MDR-TB/HIV co-infected patients under treatment.

<p>Adverse drug reactions in MDR-TB/HIV co-infected patients under treatment.</p

CD4 evolution over time in MDR-TB/HIV co-infected patients under ART and MDR-TB treatment, Mumbai, India.

<p>CD4 evolution over time in MDR-TB/HIV co-infected patients under ART and MDR-TB treatment, Mumbai, India.</p

Treatment regimens of HIV-infected MDR-TB patients (n = 67).

*<p>for at least two weeks.</p

Flowchart of patients with MDR-TB/HIV co-infection enrolled in care between 2006 and 2011, Mumbai, India.

<p>Flowchart of patients with MDR-TB/HIV co-infection enrolled in care between 2006 and 2011, Mumbai, India.</p