Early Treatment Outcomes and HIV Status of Patients With Extensively Drug-Resistant Tuberculosis in South Africa: A Retrospective Cohort Study

Reports from South Africa's KwaZulu-Natal province suggest that almost all extensively drug-resistant TB (XDR TB) patients were HIV-positive, with a fatal result. Given the scarcity of data on XDR TB in settings with high HIV prevalence, the current retrospective cohort study examined the associations of HIV and XDR-TB to formulate recommendations for control programs.

The authors investigated case records of XDR TB patients with culture-proven diagnoses between August 2002 and February 2008 at four provincial treatment facilities. The study used Cox proportional hazards regression models to evaluate risk factors of mortality and culture conversion.

Of 227 patients over age 16, 195 were analyzed. Before any treatment was initiated, 21 died. Of 174 patients who began treatment (82 HIV-positive), 62 (36 percent) died during follow-up. However, the number of deaths was not significantly different between HIV-positive or -negative patients. Among those with HIV, 34 of 82 (41 percent) died, compared with 28 of 92 (30 percent) among patients without HIV (p=0.13).

Independent predictors of death included treatment with moxifloxacin (hazard ratio 0.11, 95 percent confidence interval 0.01-0.82; p=0.03), previous culture-proven multidrug-resistant TB (5.21, 1.93-14.1; p=0.001), and number of drugs used in a regimen (0.59, 0.45-0.78; p<0.0001). Among HIV patients, fewer died who were given antiretroviral therapy than those who were not (0.38, 0.18-0.80; p=0.01).

Of the 174 patients treated, 33 (19 percent) showed culture conversion, including 23 (70 percent) with conversion within six months of treatment initiation.

"In South Africa, patients with XDR TB, a substantial proportion of whom are not infected with HIV, have poor management outcomes," the authors conclude. "Nevertheless, survival in patients with HIV infection is better than previously reported. The priorities for the country are still prevention of XDR TB, and early detection and management of multidrug-resistant TB and XDR TB through strengthened programs and laboratory capacity."

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