Community-based treatment of drug-resistant tuberculosis in Khayelitsha, South Africa

SETTING: Khayelitsha, South Africa, a peri-urban township with high burdens of tuberculosis (TB), drug-resistant tuberculosis (DR-TB), and human immunodeficiency virus (HIV) infection. OBJECTIVE: To describe case detection and patient outcomes in a community-based DR-TB programme. DESIGN: DR-TB management was integrated into primary health care in Khayelitsha from 2007 onwards. Implementation was incremental, and included training and clinician support, counselling and home visits, tuberculous infection control, a local in-patient service, and routine monitoring. Patients received treatment rapidly through their local clinic, and were only hospitalised if clinically unwell. RESULTS: DR-TB case notification (any rifampicin resistance) increased from 28 per 100 000 population per year (2005-2007) to 55/100 000/year in 2009-2011 (72% HIV-infected). From 2008 to 2011, 754 patients received treatment (86% of those diagnosed). The median time between diagnostic sputum and treatment decreased over the years of implementation to 27 days in 2011 (P < 0.001). Treatment success was 52% in 2010, with 31% default, 13% death and 4% treatment failure. Two-year survival was 65%, with poorer survival in those with HIV (HR 2.0, 95%CI 1.4-2.8), second-line drug resistance (HR 3.3, 95%CI 2.2-4.8), and diagnosis in earlier programme years (HR 1.4, 95%CI 1.1-2.0). CONCLUSION: Community-based DR-TB management is feasible, and contributes to improved case detection, reduced treatment delay and improved survival. Treatment outcomes remain poor, highlighting the poor efficacy, tolerability and lengthy duration of current treatment.