How Do Patients Who Fail First-Line TB Treatment but Who Are Not Placed on an MDR-TB Regimen Fare in South India?

SETTING: Seven districts in Andhra Pradesh, South India. OBJECTIVES: To a) determine treatment outcomes of patients who fail first line anti-TB treatment and are not placed on an multi-drug resistant TB (MDR-TB) regimen, and b) relate the treatment outcomes to culture and drug susceptibility patterns (C&DST). DESIGN: Retrospective cohort study using routine programme data and Mycobacterium TB Culture C&DST between July 2008 and December 2009. RESULTS: There were 202 individuals given a re-treatment regimen and included in the study. Overall treatment outcomes were: 68 (34%) with treatment success, 84 (42%) failed, 36 (18%) died, 13 (6.5%) defaulted and 1 transferred out. Treatment success for category I and II failures was low at 37%. In those with positive cultures, 81 had pan-sensitive strains with 31 (38%) showing treatment success, while 61 had drug-resistance strains with 9 (15%) showing treatment success. In 58 patients with negative cultures, 28 (48%) showed treatment success. CONCLUSION: Treatment outcomes of patients who fail a first-line anti-TB treatment and who are not placed on an MDR-TB regimen are unacceptably poor. The worst outcomes are seen among category II failures and those with negative cultures or drug-resistance. There are important programmatic implications which need to be addressed

Feasibility and effectiveness of provider initiated HIV testing and counseling of TB suspects in Vizianagaram district, South India.

BACKGROUND: Though internationally recommended, provider initiated HIV testing and counseling (PITC) of persons suspected of tuberculosis (TB) is not a policy in India; HIV seroprevalence among TB suspects has never been reported. The current policy of PITC for diagnosed TB cases may limit opportunities of early HIV diagnosis and treatment. We determined HIV seroprevalence among persons suspected of TB and assessed feasibility and effectiveness of PITC implementation at this earlier stage in the TB diagnostic pathway. METHODS: All adults examined for diagnostic sputum microscopy (TB suspects) in Vizianagaram district (population 2.5 million), in November-December 2010, were offered voluntary HIV counseling and testing (VCT) and assessed for TB diagnosis. RESULTS: Of 2918 eligible TB suspects, 2465(85%) consented to VCT. Among these, 246(10%) were HIV-positive. Of the 246, 84(34%) were newly diagnosed as HIV (HIV status not known previously). To detect a new case of HIV infection, the number needed to screen (NNS) was 26 among 'TB suspects', comparable to that among 'TB patients'. Among suspects aged 25-54 years, not diagnosed as TB, the NNS was 17. CONCLUSION: The seroprevalence of HIV among 'TB suspects' was as high as that among 'TB patients'. Implementation of PITC among TB suspects was feasible and effective, detecting a large number of new HIV cases with minimal additional workload on staff of HIV testing centre. HIV testing of TB suspects aged 25-54 years demonstrated higher yield for a given effort, and should be considered by policy makers at least in settings with high HIV prevalence

Tuberculosis management practices by private practitioners in Andhra Pradesh, India.

SETTING: Private medical practitioners in Visakhapatnam district, Andhra Pradesh, India. OBJECTIVES: To evaluate self-reported TB diagnostic and treatment practices amongst private medical practitioners against benchmark practices articulated in the International Standards of Tuberculosis Care (ISTC), and factors associated with compliance with ISTC. DESIGN: Cross- sectional survey using semi-structured interviews. RESULTS: Of 296 randomly selected private practitioners, 201 (68%) were assessed for compliance to ISTC diagnostic and treatment standards in TB management. Only 11 (6%) followed a combination of 6 diagnostic standards together and only 1 followed a combination of all seven treatment standards together. There were 28 (14%) private practitioners who complied with a combination of three core ISTC (cough for tuberculosis suspects, sputum smear examination and use of standardized treatment). Higher ISTC compliance was associated with caring for more than 20 TB patients annually, prior sensitization to TB control guidelines, and practice of alternate systems of medicine. CONCLUSION: Few private practitioners in Visakhapatnam, India reported TB diagnostic and treatment practices that met ISTC. Better engagement of the private sector is urgently required to improve TB management practices and to prevent diagnostic delay and drug resistance

Number needed to screen to find an additional case of HIV, by strategy, Vizianagaram district, India, November-December 2010.

<p>TB –Tuberculosis; HIV –Human immunodeficiency virus; NNS-Number needed to screen.</p

Increase in workload at HIV testing centers due to strategy of ‘routine HIV testing of TB suspects’, Vizianagaram district, India, November-December 2010.

<p>HIV-Human immunodeficiency virus; ICTC-Integrated counseling and testing centre.</p

Demographic and clinical characteristics of the study population, Vizianagaram district, India, November-December 2010.

<p>TB – Tuberculosis; HIV – Human immunodeficiency virus; df-degrees of freedom.</p

Newly detected HIV infections among TB patients and TB suspects, Vizianagaram district, India, November-December 2010.

<p>TB – Tuberculosis; HIV – Human immunodeficiency virus.</p

Private Practitioners adhering to ISTC^* diagnostic practices in Visakhapatnam, Andhra Pradesh.

<p><b>*(International Standards of TB Care).</b></p><p><b>TB = tuberculosis;</b></p><p><b>*Response to what antibiotic was used as trial antibiotic. 85 (53%) used non-fluoroquinolones.</b></p><p><b>**5 approaches included history, clinical examination, Tuberculin skin testing, bacteriological evaluation or relevant investigations to diagnose e.g. cervical lymph node TB.</b></p

Characteristics of private practitioners in relation to compliance with 3 selected core ISTC^* in Visakhapatnam, AP.

<p><b>*(International Standards of TB Care).</b></p><p><b>Core ISTC Standards: Standard 1 = Using 2–3 weeks cough for identification of Pulmonary TB suspects; Standard 2 = Using sputum smear microscopy examination; and Standard 6 = Treatment with the standard 6-month regimen; TB = Tuberculosis; AYUSH = Ayurveda, Unani, Siddha, Homeopathy; RNTCP = Revised National TB Control Programme; RR = Relative Risk has been calculated for standard 1+2+8; CI = Confidence Interval.</b></p

Box 2- Decision aid for analysis.

<p>This is a decision aid for the purpose of analysis of data; the type of question asked in the questionnaire, subject of the question and the responses which should be considered as compliant against each diagnostic and treatment standard are summarized.</p