Abstract
BackgroundLittle is known about the treatment of multidrug-resistant tuberculosis (MDR-TB) in HIV-co-infected adolescents. This study aimed to present the intermediate outcomes of HIV-infected adolescents aged 10–19 years receiving second-line anti-TB treatment in a Médecins Sans Frontières (MSF) project in Mumbai, India.MethodsA retrospective review of medical records of 11 adolescents enrolled between July 2007 and January 2013 was undertaken. Patients were initiated on either empirical or individualized second-line ambulatory anti-TB treatment under direct observation.ResultsThe median age was 16 (IQR 14–18) years and 54% were female. Five (46%) adolescents had pulmonary TB (PTB), two (18%) extrapulmonary disease (EPTB) and four (36%) had both. Median CD4 count at the time of MDR-TB diagnosis was 162.7 cells/µl (IQR: 84.8–250.5). By January 2013, eight patients had final and 3 had interim outcomes. Favourable results were seen in four (36.5%) patients: one was cured and three were still on treatment with negative culture results. Seven patients (64%) had poor outcomes: four (36.5%) died and three (27%) defaulted. Three of the patients who died never started on antiretroviral and/or TB treatment and one died 16 days after treatment initiation. Two of the defaulted died soon after default. All patients (100%) on-treatment experienced adverse events (AEs): two required permanent discontinuation of the culprit drug and two were hospitalized due to AEs. No patient required permanent discontinuation of the entire second-line TB or antiretroviral regimens.ConclusionsEarly mortality and mortality after default were the most common reasons for poor outcomes in this study. Early mortality suggests the need for rapid diagnosis and prompt treatment initiation, and adolescents might benefit from active contact-tracing and immediate referral. Default occurred at different times, suggesting the need for continuous, intensified and individualized psychosocial support for co-infected adolescents. Operational research among co-infected adolescents will be especially important in designing effective interventions for this vulnerable group.
Highlights
Multidrug-resistant tuberculosis (MDR-TB)–defined as strains of TB with in vitro resistance to at least isoniazid and rifampin–is a major public health problem [1]
Fewer than 40,000 patients have been put on World Health Organization (WHO)-recommended therapy in the last decade [2]
Five patients were on Antiretroviral therapy (ART) at the time of the multidrug-resistant tuberculosis (MDR-TB) diagnosis: two of them were on ART for more than 2 years and three of them for six months or less
Summary
Multidrug-resistant tuberculosis (MDR-TB)–defined as strains of TB with in vitro resistance to at least isoniazid and rifampin–is a major public health problem [1]. Inadequate diagnosis and treatment of MDR-TB is even worse in children, who represent an estimated 10–20% of all cases, up to 80,000 each year [3,4]. Adolescence is a time period during which children must transition into adult roles; there may be increased time constraints due to school, work or family responsibilities [18,19,20]. All of these issues can affect the health outcomes of adolescent populations with chronic diseases, such as MDR-TB. This study aimed to present the intermediate outcomes of HIV-infected adolescents aged 10–19 years receiving second-line anti-TB treatment in a Medecins Sans Frontieres (MSF) project in Mumbai, India
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