Loss from treatment for drug resistant tuberculosis: risk factors and patient outcomes in a community-based program in Khayelitsha, South Africa

BACKGROUND: A community based drug resistant tuberculosis (DR-TB) program has been incrementally implemented in Khayelitsha, a high HIV and TB burden community in South Africa. We investigated loss from treatment (LFT), and post treatment outcomes of DR-TB patients in this setting. METHODOLOGY: LFT, defined as interruption of treatment for ≥2 consecutive months was assessed among patients initiating DR-TB treatment for the first time between January 2009 and July 2011. Patients were traced through routine data sources to identify those who subsequently restarted treatment and those who died. Additional information on patient status and survival after LTF was obtained from community DR-TB counselors and from the national death registry. Post treatment outcomes were observed until July 2013. RESULTS: Among 452 patients initiating treatment for the first time within the given period, 30% (136) were LFT, with 67% retention at 18 months. Treatment was restarted in 27 (20%) patients, with additional resistance recorded in 2/25 (8%), excluding two with presumed DR-TB. Overall, 34 (25%) patients died, including 11 who restarted treatment. Males and those in the age category 15-25 years had a greater hazard of LFT; HR 1.93 (95% CI 1.35-2.75), and 2.43 (95% CI 1.52-3.88) respectively. Older age (>35 years) was associated with a greater hazard of death; HR 3.74 (1.13- 12.37) post treatment. Overall two-year survival was 62%. It was lower (45%) in older patients, and was 92% among those who received >12 months treatment. CONCLUSION: LFT was high, occurred throughout the treatment period and was particularly high among males and those aged 15-25 years. Overall long term survival was poor. High rates of LFT should however not preclude scale up of community based care given its impact in increasing access to treatment. Further research is needed to support retention of DR-TB patients on treatment, even within community based treatment programs

Demographic characteristics of patients who started treatment between January 2009 and July 2011 who had treatment outcomes by July 2013 (N = 452).

<p>PHC-Primary Health Care</p><p>MDR- multidrug resistance</p><p>Demographic characteristics of patients who started treatment between January 2009 and July 2011 who had treatment outcomes by July 2013 (N = 452).</p

Retention on treatment: Patients remaining on treatment over the course of treatment (n = 393).

<p>Retention on treatment: Patients remaining on treatment over the course of treatment (n = 393).</p

Survival post treatment: Overall, Duration of treatment before LFT, and Age at DR-TB diagnosis.

<p>Survival post treatment: Overall, Duration of treatment before LFT, and Age at DR-TB diagnosis.</p

Association of factors with time to loss from DR-TB treatment—2009–2013 (n = 373^*).

<p>* 79 patients who died while on treatment were excluded from this analysis</p><p>^#statistically significant</p><p>^ Sensitivity analysis-Multivariate analysis including Culture conversion status at 4 months of treatment</p><p>Association of factors with time to loss from DR-TB treatment—2009–2013 (n = 373^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0118919#t002fn001" target="_blank">*</a>}).</p

Post treatment outcomes of the patients lost from DR-TB treatment (January 2009-July 2013).

<p>Post treatment outcomes of the patients lost from DR-TB treatment (January 2009-July 2013).</p