Treatment initiation among persons diagnosed with drug resistant tuberculosis in Johannesburg, South Africa

PLoS One. 2017 Jul 26;12(7):e0181238. doi: 10.1371/journal.pone.0181238. eCollection 2017.

Abstract

Background: In South Africa, roughly half of the drug-resistant TB cases diagnosed are reported to have been started on treatment. We determined the proportion of persons diagnosed with rifampicin resistant (RR-) TB who initiated treatment in Johannesburg after the introduction of decentralized RR-TB care in 2011.

Methods: We retrospectively matched adult patients diagnosed with laboratory-confirmed RR-TB in Johannesburg from 07/2011-06/2012 with records of patients initiating RR-TB treatment at one of the city's four public sector treatment sites (one centralized, three decentralized). Patients were followed from date of diagnosis until the earliest of RR-TB treatment initiation, death, or 6 months' follow-up. We report diagnostic methods and outcomes, proportions initiating treatment, and median time from diagnosis to treatment initiation.

Results: 594 patients were enrolled (median age 34 (IQR 29-42), 287 (48.3%) female). Diagnosis was by GenoType MTBDRplus (Hain-Life-Science) line probe assay (LPA) (281, 47.3%), Xpert MTB/RIF (Cepheid) (258, 43.4%), or phenotypic drug susceptibility testing (DST) (30, 5.1%) with 25 (4.2%) missing a diagnosis method. 320 patients (53.8%) had multi-drug resistant TB, 158 (26.6%) rifampicin resistant TB by Xpert MTB/RIF, 102 (17.2%) rifampicin mono-resistance, and 14 (2.4%) extensively drug-resistant TB. 256/594 (43.0%) patients initiated treatment, representing 70.7% of those who were referred for treatment (362/594). 338/594 patients (57.0%) did not initiate treatment, including 104 (17.5%) who died before treatment was started. The median time from sputum collection to treatment initiation was 33 days (IQR 12-52).

Conclusion: Despite decentralized RR-TB treatment, fewer than half the patients diagnosed in Johannesburg initiated appropriate treatment. Offering treatment at decentralized sites alone is not sufficient; improvements in linking patients diagnosed with RR-TB to effective treatment is essential.

MeSH terms

  • Adult
  • Antibiotics, Antitubercular / pharmacology
  • Antitubercular Agents / therapeutic use*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Mycobacterium tuberculosis / drug effects*
  • Outcome Assessment, Health Care / methods
  • Outcome Assessment, Health Care / statistics & numerical data
  • Primary Health Care / methods
  • Primary Health Care / statistics & numerical data*
  • Proportional Hazards Models
  • Public Sector / statistics & numerical data*
  • Retrospective Studies
  • Rifampin / pharmacology
  • South Africa
  • Sputum / microbiology
  • Survival Analysis
  • Time Factors
  • Tuberculosis, Multidrug-Resistant / diagnosis
  • Tuberculosis, Multidrug-Resistant / drug therapy*
  • Tuberculosis, Multidrug-Resistant / microbiology

Substances

  • Antibiotics, Antitubercular
  • Antitubercular Agents
  • Rifampin

Grants and funding

DE, TS, CG, RB, SR and LL are supported through the South Africa Mission of the US Agency for International Development (USAID) under the terms of cooperative agreement 674-A-12-00029 to the Health Economics and Epidemiology Research Office. KS and RB were supported by a cooperative agreement from the USAID to Right to Care 674-A-12-00020. AB was supported by USAID cooperative agreement number 674-12-00002 to Wits Reproductive Health and HIV Research Institute. This study was made possible by the generous support of the American people through USAID. The contents of the article are the responsibility of the authors and do not necessarily reflect the views of USAID or the Unites States Government. The funders had no role in the study design, collection, analysis and interpretation of the data, in manuscript preparation or the decision to publish.