appears to take a different and more aggressive course. Most patients with HIV-associated MDR and XDR TB die within 6 to 8 weeks, which is also the time typically required to make the diagnosis by conventional culture and drug sensitivity testing. Thus, the majority of patients die before their diagnosis can be documented and before second-line drug treatment can be initiated.1 A third issue concerns the locus of treatment. On the one hand, it was noted that XDR TB treatment, especially in the earliest stages, should take place in a hospital to ensure management of side effects, treatment literacy in patients, nutritional support, and infection control. On the other hand, it was argued that a move toward a decentralized model of care is necessary for prevention of transmission. For example, as the number of patients on antiretroviral therapy increases, antiretroviral therapy facilities will become more crowded with patients, many of whom are highly susceptible to TB. It is important to recognize that combining HIV and TB programs could result in spreading TB among HIV-infected people. A final set of challenges relates to limitations of health care systems and cost issues.

TREATMENT OF DRUG-RESISTANT TB

General Principles

Presenters offered general principles for the treatment of drug-resistant TB, including the need for a comprehensive approach that includes intensified case finding, preventive therapy, improved treatment literacy, and good infection control. In addition, presenters suggested that patients should have increased access to anti-TB drugs as well as other treatment modalities, including thoracic surgery and immune modulators.

Nesri Padayatchi, University of KwaZulu-Natal, elaborated on the objectives of MDR TB management in KwaZulu-Natal Province:

  • to make the diagnosis of MDR TB in patients,

  • to ensure that the best possible treatment is available,

  • to provide support for each patient to ensure access to treatment,

  • to facilitate the continuation of care for each patient,

  • to factor the management of HIV into the treatment of TB, and

  • to explore other options for treatment.

Gandhi described the program that has been instituted in Tugela Ferry, which has three main components:

1

As noted in Chapter 2, World Health Organization (WHO) and International Standards for Tuberculosis Care (ISTC) guidelines promote the use of an empiric regimen of second-line drugs in suspected MDR TB patients (TBCTA, 2009).



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