Twice-weekly, directly observed treatment for HIV-infected and uninfected tuberculosis patients: Cohort study in rural South Africa
University of KwaZulu-Natal, Port Natal, KwaZulu-Natal, South Africa AIDS
(Impact Factor: 5.55).
06/1999; 13(7):811-7. DOI: 10.1097/00002030-199905070-00010
To determine the effectiveness of twice-weekly directly observed therapy (DOT) for tuberculosis (TB) in HIV-infected and uninfected patients, irrespective of their previous treatment history. Also to determine the predictive value of 2-3 month smears on treatment outcome.
Four hundred and sixteen new and 113 previously treated adults with culture positive pulmonary TB (58% HIV infected, 9% combined drug resistance) in Hlabisa, South Africa. Daily isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E) given in hospital (median 17 days), followed by HRZE twice a week to 2 months and HR twice a week to 6 months in the community.
Outcomes at 6 months among the 416 new patients were: transferred out 2%; interrupted treatment 17%; completed treatment 3%; failure 2%; and cured 71%. Outcomes were similar among HIV-infected and uninfected patients except for death (6 versus 2%; P = 0.03). Cure was frequent among adherent HIV-infected (97%; 95% CI 94-99%) and uninfected (96%; 95% CI 92-99%) new patients. Outcomes were similar among previously treated and new patients, except for death (11 versus 4%; P = 0.01), and cure among adherent previously treated patients 97% (95% CI 92-99%) was high. Smear results at 2 months did not predict the final outcome.
A twice-weekly rifampicin-containing drug regimen given under DOT cures most adherent patients irrespective of HIV status and previous treatment history. The 2 month smear may be safely omitted. Relapse rates need to be determined, and an improved system of keeping treatment interrupters on therapy is needed. Simplified TB treatment may aid implementation of the DOTS strategy in settings with high TB caseloads secondary to the HIV epidemic.
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- "Direct treatment of opportunistic infections in HIV positive patients can be effective (for example, Grant, Kaplan and Cock, 2001). In particular, the standard treatment of tuberculosis (directly observed treatment, short course) is highly effective in general and can be equally effective in HIV-positive patients (Davies et al.,1999). HIV-positive patients with tuberculosis can also be given drugs to prevent the onset of pneumonia, which can dramatically reduce mortality rates. "
Available from: Frank Tanser
- "Although community-based therapy has long been known to be safe and effective (Tuberculosis Chemotherapy Centre Madras 1959), there is limited modern experience with it (Bayer & Wilkinson 1995). In the Hlabisa health district, South Africa, the tuberculosis control programme started using community-based treatment in 1991 (Wilkinson 1994) and high levels of treatment adherence (Wilkinson et al. 1996) and cure (Davies et al. 1998) have been achieved. In 1998 a district-wide GIS was established. "
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ABSTRACT: We used GIS/GPS technology to document and quantify improved access to tuberculosis treatment through a community-based programme in Hlabisa, South Africa. We plotted tuberculosis supervision points used by the district health system in 1991 (programme's first year) and 1996 (programme fully established), and quantified access by using GIS to measure the mean distance from each homestead in the district to hospital, clinics, community health workers (CHW) and volunteer supervisors. While the tuberculosis caseload tripled, the number of community supervision points used increased from 37 in 1991 to 147 in 1996. Adding clinics and then CHWs to the hospital as treatment points reduced the mean distance from homestead to treatment point from 29.6 km to 4.2 km and to 1.9 km, respectively. Adding volunteers further decreased the distance to 800 m. GIS/GPS effectively documents and quantifies the impact of community-based tuberculosis treatment on access to treatment.
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