RESUMO
Monthly culture is usually recommended to monitor treatment of multidrug-resistant tuberculosis (MDR-TB). As mycobacterial laboratory capacity is limited in many settings, TB programs need evidence to decide whether monthly cultures are necessary compared to other approaches. We simulated three alternative monitoring strategies (culture every 2 or 3 months, and monthly smears alone) in a cohort of MDR-TB patients in Estonia, Latvia, Philippines, Russia and Peru from 2000 to 2004. This retrospective analysis illustrated that less frequent testing delays confirmation of bacteriological conversion. This would prolong intensive treatment, hospitalization and respiratory isolation, increasing cost and toxicity. After conversion, less frequent testing could delay diagnosis of possible treatment failure.
Assuntos
Antituberculosos/uso terapêutico , Técnicas Bacteriológicas , Monitoramento de Medicamentos/métodos , Farmacorresistência Bacteriana Múltipla , Mycobacterium tuberculosis/efeitos dos fármacos , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Adulto , Simulação por Computador , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Mycobacterium tuberculosis/crescimento & desenvolvimento , Mycobacterium tuberculosis/isolamento & purificação , Peru/epidemiologia , Filipinas/epidemiologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Escarro/microbiologia , Fatores de Tempo , Falha de Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/microbiologiaRESUMO
BACKGROUND: Although multidrug-resistant tuberculosis (MDR-TB) is a major global health problem, there is a gap in programmatic treatment implementation. METHODS: This study describes MDR-TB treatment models in three countries--Peru, Russia and Lesotho-- using qualitative data collected over a 13-year period. RESULTS: A program analysis is presented for each country focusing on baseline medical care, initial implementation and program evolution. A pattern analysis revealed six overarching themes common to all three programs: 1) importance of baseline assessments, 2) early identification of key collaborators, 3) identification of initial locus of care, 4) minimization of patient-incurred costs, 5) targeted interventions for vulnerable populations and 6) importance of technical assistance and funding. Site commonalities and differences in each of these areas were analyzed. CONCLUSIONS: It is recommended that all programs providing MDR-TB treatment address these six areas during program development and implementation.
Assuntos
Antituberculosos/uso terapêutico , Prestação Integrada de Cuidados de Saúde/organização & administração , Farmacorresistência Bacteriana Múltipla , Acessibilidade aos Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/organização & administração , Modelos Organizacionais , Programas Nacionais de Saúde/organização & administração , Avaliação de Processos e Resultados em Cuidados de Saúde , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Serviços de Saúde Comunitária/organização & administração , Comportamento Cooperativo , Prestação Integrada de Cuidados de Saúde/economia , Financiamento Pessoal , Custos de Cuidados de Saúde , Acessibilidade aos Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/economia , Disparidades em Assistência à Saúde , Humanos , Lesoto/epidemiologia , Programas Nacionais de Saúde/economia , Objetivos Organizacionais , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Equipe de Assistência ao Paciente/organização & administração , Peru/epidemiologia , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Federação Russa/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Tuberculose Resistente a Múltiplos Medicamentos/economia , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Populações VulneráveisRESUMO
BACKGROUND: Multidrug-resistant tuberculosis programs in DOTS-Plus pilot sites in five countries. OBJECTIVES: To calculate sputum conversion time and its relationship to treatment outcome, document the frequency of culture reversions and examine concordance of smear and culture to assess the potential consequences of monitoring by smear microscopy alone. DESIGN: Retrospective cohort analysis of 1926 patients receiving individualized, second-line therapy. RESULTS: Among 1385 sputum culture-positive cases at baseline, 1146 (83%) experienced at least one culture conversion during treatment. Conversion, however, was not sustained in all patients: 201 (15%) experienced initial culture conversion and at least one subsequent culture reversion to positive; 1064 (77%) achieved sustained culture conversion. Median time to culture conversion was 3 months. Among 206 patients whose nal conversion occurred 7-18 months after the initiation of therapy, 71% were cured or had completed treatment. CONCLUSIONS: Prolonged treatment for patients with delayed conversion may be beneficial, as 71% of late converters still achieved cure or completed treatment. This has implications for programs with de ned end points for treatment failure. The interval between rst and nal conversion among patients whose initial con- version is not sustained raises concern with respect to the ongoing debate regarding duration of treatment and the definition of cure.
Assuntos
Antituberculosos/administração & dosagem , Técnicas Bacteriológicas , Terapia Diretamente Observada , Monitoramento de Medicamentos/métodos , Farmacorresistência Bacteriana Múltipla , Mycobacterium tuberculosis/efeitos dos fármacos , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Esquema de Medicação , Estônia , Feminino , Humanos , Letônia , Masculino , Testes de Sensibilidade Microbiana , Microscopia , Mycobacterium tuberculosis/isolamento & purificação , Peru , Filipinas , Projetos Piloto , Estudos Retrospectivos , Federação Russa , Escarro/microbiologia , Fatores de Tempo , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Tuberculose Resistente a Múltiplos Medicamentos/microbiologiaRESUMO
In the last 25 years, human immunodeficiency virus (HIV) has become the leading infectious killer of adults globally, with an estimated 44 million people infected with the virus worldwide. Most of these individuals live in poor regions of the world, particularly sub-Saharan Africa. Although a great deal of work has been done in identifying and treating individuals with the disease, there has been little action to date to address the complex socioeconomic factors that lie at the heart of this global pandemic. Understanding and responding to such factors is of paramount importance if HIV infection is to be managed in a meaningful way. This article explores the social context of people living with HIV in three different geographic and epidemiologic settings and highlights the social factors that shape and define an individual's risk of acquiring HIV. It also discusses unique programs aimed at addressing the complex realities of the world in which HIV thrives. These programs can act as models of HIV prevention and treatment.