HIV-positive patients treated for multidrug-resistant tuberculosis: clinical outcomes in the HAART era.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) and the human immunodeficiency virus (HIV) pose two of the greatest threats to global tuberculosis (TB) control. Given expanding global access to antiretroviral therapy (ART) and second-line TB drugs, more data are needed on experiences treating MDR-TB and HIV co-infection in resource-poor settings. OBJECTIVE: To describe the clinical characteristics, management, outcomes, and factors associated with survival among HIV-positive individuals receiving treatment for MDR-TB. DESIGN: This was a retrospective case series of 52 HIV-positive individuals receiving treatment for MDR-TB in Lima, Peru. We used Cox proportional hazards regression models to identify risk factors for mortality. RESULTS: A total of 31 (57%) of the cohort died on treatment, with the majority of deaths due to MDR-TB. Low baseline weight predicted a three-fold increased rate of death (aHR 3.1, 95%CI 1.5-6.7), while individuals receiving highly active ART experienced a significantly lower rate of death compared to those who were not (aHR 0.4, 95%CI 0.2-0.9). CONCLUSION: Early ART is likely a key component of effective MDR-TB management in co-infected individuals.

Nurses as providers of emotional support to patients with MDR-TB.

AIM: To identify the forms and means of emotional support that nurses provide to patients living with multidrug-resistant tuberculosis (MTR-TB) in Lima, Peru. BACKGROUND: A fundamental role of nurses is to provide emotional support, defined as all the strategies that a health team employs to assure the psychosocial well-being of the patient. However, neither the forms of emotional support nor the means used by nurses in resource-poor settings have been much written about. This paper describes a qualitative study of a team of seven nurses working in a programme that provides individualized MDR-TB treatment to patients in Lima, Peru. It describes the various forms of support that facilitated the ability of patients to adhere to treatment despite socio-economic difficulties, social stigma, drug side effects, problems related to different stages of treatment and concurrent illnesses/special situations. METHODS: Qualitative study methods were employed over the course of 8 years to observe nurses and patients in an MDR-TB treatment programme. These included participant observation, structured observation sessions of nurses with their patients and focus groups with seven nurses. CONCLUSION: Through theme and content analyses of qualitative data, ten situations related to MDR-TB treatment were found. These ten issues served as an analytical framework used to identify and discuss the various types of emotional support provided by both formal and informal means. This type of support focused on problems related to different stages of treatment, social stigma of the illness, treatment adherence, side effects, socio-economic difficulties, death and concurrent illnesses/special situations. PRACTICE IMPLICATIONS: The essential role of the nurse as a provider of emotional support in the development or implementation of similar programmes with MDR-TB should, in future, be taken into account.

Contact investigations as a means of detection and timely treatment of persons with infectious multidrug-resistant tuberculosis.

SETTING: Two regions of metropolitan Lima, Peru. OBJECTIVE: To determine the outcomes of two contact investigation strategies used in therapy enrollment cohorts of patients with multidrug-resistant tuberculosis (MDR-TB). DESIGN: From 28 August 1996 to 31 December 1999, 91 index patients received individualized MDR-TB therapy (Group A), and from 1 October 1997 to 31 December 1999, another 101 index patients received a standardized MDR-TB regimen (Group B). We conducted a retrospective chart review and home visits to identify secondary cases among close contacts of both of these groups. Group A secondary cases with MDR-TB received therapy based on the drug susceptibility profile of their infecting strain, while Group B secondary cases received standard short-course therapy. RESULTS: Among 945 close contacts, 72 secondary TB cases (8%) were found. Of 42 who had drug-susceptibility testing, 35 (84%) were MDR-TB, but only seven (17%) had the same drug susceptibility profile as the index case. Cure exceeded 80% in Group A secondary cases, while only half of Group B secondary cases were cured (RR 1.6, 95%CI 1.1-2.2). CONCLUSION: Contact investigation protocols coupled with enrollment in MDR-TB therapy are a useful means of detecting and promptly treating persons with infectious MDR-TB. In settings with endemic MDR strains of Mycobacterium tuberculosis, effective therapy of contacts of MDR-TB patients requires knowledge of drug susceptibility for each contact with active disease.

The role of the nurse in the community-based treatment of multidrug-resistant tuberculosis (MDR-TB).

SETTING: A community-based treatment program for multidrug-resistant tuberculosis (MDR-TB) in Lima, Peru. OBJECTIVES: To describe the activities carried out by the nurses working with the program. DESIGN: A qualitative study using a variety of ethnographic methods, including participant observation, focus groups, and key informant interviews over a 5-year period. RESULTS: Nurses were responsible for carrying out a wide variety of activities within the program. These included patient-focused activities such as identifying patients, evaluating patients prior to starting and during therapy, and managing emergencies; educational activities for both patients and health professionals managing MDR-TB; and coordination activities, including over-seeing health workers and communicating between team members. CONCLUSION: Nurses play a key role in the community-based management of MDR-TB.