Early Outcomes Of Decentralized Care for Rifampicin-Resistant Tuberculosis in Johannesburg, South Africa: An Observational Cohort Study

• Published in: PloS one 2016-11, Vol.11 (11), p.e0164974-e0164974
• Main Authors: Berhanu, Rebecca, Schnippel, Kathryn, Mohr, Erika, Hirasen, Kamban, Evans, Denise, Rosen, Sydney, Sanne, Ian
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; Adult; AIDS; Analysis; Antiretroviral drugs; Antitubercular Agents - pharmacology; Antitubercular Agents - therapeutic use; Biology and Life Sciences; Care and treatment; CD4 antigen; Cell culture; Clinical outcomes; Cohort analysis; Cohort Studies; Diagnosis; Diagnostic systems; Drug resistance; Drug Resistance, Bacterial; Epidemiology; Female; Health economics; Health sciences; HIV; Hospitals; Human immunodeficiency virus; Humans; Internal medicine; Lentivirus; Male; Medical diagnosis; Medical research; Medicine; Medicine and Health Sciences; Middle Aged; Mycobacterium; Observational studies; Outcome Assessment (Health Care); Patient outcomes; Patients; Public sector; Retroviridae; Rifampin; Rifampin - pharmacology; South Africa; Sputum; Systematic review; Time Factors; Treatment Outcome; Tuberculosis; Tuberculosis, Pulmonary - drug therapy
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0164974

We describe baseline characteristics, time to treatment initiation and interim patient outcomes at a decentralized, outpatient treatment site for rifampicin-resistant TB (RR-TB). Prospective observational cohort study of RR-TB patients from March 2013 until December 2014. Study subjects were followed until completion of the intensive phase of treatment (6 months), transfer out, or a final outcome (loss from treatment (LFT) or death). 214 patients with RR-TB were enrolled in the study. Xpert MTB/RIF was the diagnostic test of rifampicin resistance for 87% (n = 186), followed by direct PCR on AFB positive specimen in 14 (7%) and indirect PCR on cultured isolate in 5 (2%). Median time between sputum testing and treatment initiation was 10 days (IQR 6-21). Interim outcomes were available in 148 patients of whom 78% (n = 115) were still on treatment, 9% (n = 13) had died, and 14% (n = 20) were LFT. Amongst 131 patients with culture positive pulmonary TB, 85 (64.9%) were culture negative at 6 months, 12 were still sputum culture positive (9.2%) and 34 had no culture documented or contaminated culture (26%). Patients who initiated as outpatients within 1 week of sputum collection for diagnosis of RR-TB had a significantly lower incidence of LFT (IRR 0.30, 95% CI: 0.09-0.98). HIV co-infection occurred in 178 patients (83%) with a median CD4 count 88 cells/ml3 (IQR 27-218). Access to decentralized treatment coupled with the rapid diagnosis of RR-TB has resulted in short time to treatment initiation. Despite the lack of treatment delays, early treatment outcomes remain poor with high rates of death and loss from care.