1. Standard of Care for MDR-TB
Dr Hind Satti
Partners In Health
Lesotho

2. Lesotho: Basic Facts
Landlocked country located within South Africa (bordering Free State and KwaZulu-Natal)
Population 1.8 million
12,275 TB new cases notified in 2009
Over 2000 re treatment cases
HIV prevalence rate: 23.2% in 2005
80% of TB cases are HIV positive (NTP 2008)

3. Lesotho MDR-TB Programme
A comprehensive response to MDR-/XDR-TB in Lesotho, established by the MOHSW.
International partners include PIH, WHO, FIND, OSI
Community-based treatment and care model that includes all 10 districts
First patients enrolled in August 2007; 500 patients enrolled to date

4. National TB Reference Laboratory

5. Case Detection All HCWs including NTP staff
TB/HIV coordinators/Officers at district hospitals
Health centre nurses providing HIV/TB care
Routine HIV screening of MDR-TB patients, partners, family members
Protocol for “medium-risk” and “high-risk”
Sputum sent to national TB laboratory
Screening of household contacts

6. Botsabelo MDR-/XDR-TB Hospital

7. Patient Characteristics
Approximately 78% HIV-positive with advanced AIDS-defining conditions
Severe malnutrition
Multiple failed TB treatment regimens
Extensive TB disease
Mostly smear-positive

8. Lesotho vs. rest of the world†
*Tomsk, Latvia, Estonia, Peru, Philippines
† Nathanson et al. Adverse events in the treatment of multidrug-resistant tuberculosis: results from the DOTS-Plus initiative. Int J Tuberc Lung Dis (11):1382–1384

9. Infection Control Outpatient Inpatient
TB clinics and general outpatient clinics
Treatment supporters
Family members
Inpatient
Cross-infection of patients
Protection of health workers (TB and HIV)

10. Social assistance

11. MDR-TB/HIV
100% HIV testing during the first visit.
Early initiation of HARRT for MDRTB/HIV (10-21 days), regardless of CD4 count.
Aggressive management of side effects.
Home assessment visit before initiation.
Household contact screening and testing for TB and HIV.

12. Role of Treatment Supporter
Observe all doses
Report side effects
Provide injections.
Accompany patient for clinical evaluations
Screen for TB and HIV in household contacts.
Offer psychosocial support to the patient and the family.

13. Effect of HIV on MDR-TB mortality
Seung KJ, Omatayo DB, Keshavjee S, Furin JJ, Farmer PE, Satti H. Early outcomes of MDR-TB treatment in a high HIV-prevalence setting in Southern Africa. PLoS One Sep 25;4(9):e7186.

14. Conclusion
Diagnosis and management of MDR-TB in high HIV-prevalence settings is challenging but possible
Empiric treatment of MDR-TB is needed to decrease early mortality
Side effects are more common and earlier
Infection control at all levels: hospital, clinic, community is critical.
Community-based MDR-TB/HIV allows for rapid enrollment and closer monitoring of side effects