Download Diagnosis and treatment of MDR/XDR-tuberculosis in HIV

Diagnosis and treatment of MDR/XDR tuberculosis in HIV-infected patients in a slum setting
in Mumbai, India
Chiara Montaldo,1 Atul Dongre,1 Bhanumathi Varghese,1 Camilla Rodrigues,2 Giovanni Sotgiu,3
Rossella Centis,4 Gianbattista B Migliori,4 Emanuele Pontali,5 Tony Reid6
1MSF HIV/AIDS Comprehensive Care Clinic, Mumbai, India; 2Hinduja Hospital, Microbiology
Laboratory, Mumbai; 3University of Sassari, Hygiene and Preventive Medicine Institute, Sassari,
Italy; 4S Maugeri Foundation, Care and Research Institute, WHO Collaborating Centre for TB and
Lung Diseases, Tradate, Italy; 5Galliera Hospital, Dept of Infectious Diseases, Genoa, Italy; 6MSF,
Brussels, Belgium
Contact: [email protected]
Background
Multi- and extensively drug-resistant tuberculosis (MDR/XDR-TB) increases mortality among HIVinfected patients. Treatment is associated with adherence challenges and drug toxicities. The MSF
HIV/AIDS Comprehensive Care Clinic in Mumbai serves an extremely heavily populated urban
area with substandard housing. Treatment is on an outpatient basis in collaboration with a network
of non-governmental organisations (NGOs) and public and private directly observed therapy (DOT)
providers.
Methods
We describe the outcomes of HIV-infected patients with MDR/XDR-TB followed by the MSF clinic
from February 2006. All patients were screened for TB symptoms. Patients with confirmed
MDR/XDR-TB received daily DOT (at least five drugs) given by the provider closest to the patient’s
residence. MSF staff delivered drugs to the DOT provider monthly and telephoned weekly to
identify adherence problems. Local NGOs traced defaulters and reinforced adherence messages.
Patients visited the clinic monthly for medical assessment.
Results
Of our cumulative cohort of 611 patients (active 350), 193 were suspected of having TB and were
screened with sputum microscopy, culture, and drug susceptibility testing. 34 samples grew
Mycobacterium tuberculosis: nine were fully sensitive; 25 had drug resistance. Of the 25, 14 (56%)
were resistant to all first-line drugs and 11/22 (50%) to fluoroquinolones (three had no history of TB
treatment). MDR strains were identified in 18/25 (72%) and XDR in 2/25 (8%). Two patients
presented symptoms suggestive of extra-pulmonary TB and started MDR-TB treatment. Pulmonary
TB was diagnosed in 22 (82%) and extra-pulmonary in 5 (23%; one had both). 14 (53%) had
already received at least one full course of TB treatment. 22 (81%) received HAART (12 started
before diagnosis, 10 during treatment). 24 started TB treatment; three died before confirmation of
MDR-TB. In February 2009, six were cured (WHO definition), four had died, five defaulted, and
nine were still on treatment. 16/20 showed culture conversion. 21 received drugs with potential
thyroid toxicity. Side-effects included thyroid dysfunction (eight [30%]), tendonitis (three [11%]),
gastrointestinal disorders (three [11%]), and psychosis (two [7.4%]).
Conclusions
Our results are preliminary and the cohort is small, but integrating HIV, TB, and MDR/XDR-TB care
was feasible and essential for the correct management of these patients. Implementing MDR/XDRTB care on an outpatient basis within an HIV clinic required infection control measures and
involvement with local health structures and NGOs. Decentralised centres, easily accessible to
patients, were essential. The high rate of thyroid toxicity reinforces recommendations to monitor
and treat thyroid dysfunction.