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Adherence in the Treatment of Patients With Extensively Drug-Resistant Tuberculosis and HIV in South Africa: A Prospective Cohort Study

O'Donnell, Max R. MD, MPH*,†,‡; Wolf, Allison MPH*; Werner, Lise MSc; Horsburgh, C. Robert MD, MUS§; Padayatchi, Nesri MBChB, MSc‡,‖

JAIDS Journal of Acquired Immune Deficiency Syndromes: September 1st, 2014 - Volume 67 - Issue 1 - p 22–29
doi: 10.1097/QAI.0000000000000221
Clinical Science

Objective: Extensively drug-resistant tuberculosis (XDR-TB)/HIV coinfection is difficult to treat with frequent adverse drug reactions and associated with high mortality. Adherence to antiretroviral therapy (ARV) and second-line TB medications may reduce mortality, prevent amplification of drug resistance, and improve outcomes.

Methods: Prospective cohort study of XDR-TB patients on treatment in KwaZulu-Natal, South Africa. Adherence to ARV and TB medications was assessed separately at baseline and monthly. Knowledge, attitudes, and beliefs were assessed at baseline. Optimal adherence was defined as self-report of taking all pills in the previous 7 days; missing any pills was defined as suboptimal adherence. Primary outcome was optimal adherence 6 months after initiation of XDR-TB treatment to TB medications, ARV, and both (“dual adherence”).

Results: One hundred four XDR-TB patients (79.8% HIV coinfected, 84.3% on ARV at enrollment) were enrolled and followed monthly (median 8 visits; interquartile range: 4–12). Six-month optimal adherence was higher for ARV (88.2%) than TB medications (67.7%) (P < 0.001). Low educational attainment, male gender, and year of enrollment were independently associated with dual suboptimal adherence. At baseline, participants indicated that XDR-TB was curable (76.0%), HIV and TB were linked (81.7%), and ARV improves TB outcomes (72.1%). Baseline knowledge, attitudes, and beliefs did not predict subsequent adherence.

Conclusions: Medication adherence was significantly higher for ARV than for TB medications in this cohort. Short-course treatment regimens for drug-resistant TB with lower pill burden may increase adherence and improve outcomes in XDR-TB/HIV. Programmatic support for dual adherence is critical in the treatment of drug-resistant TB and HIV.

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*Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, NY;

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY;

Centre for Aids Program of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa;

§Department of Epidemiology, Boston University School of Public Health, Boston, MA; and

University of KwaZulu-Natal, Durban, South Africa.

Correspondence to: Max R. O'Donnell, MD, MPH, Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons, PH-8 East, Room 101, 622 West 168th Street, New York, NY 10032 (e-mail:

M.R.O. was supported by the National Institutes of Health, National Institute of Allergy and Infectious Diseases (5K23AI098479), Albert Einstein Center for Global Health & Clinical and Translational Research Institute, and Stony-Wold Herbert Fund. M.R.O. and N.P. were supported by the Centre for AIDS Programme of Research in South Africa (CAPRISA).

The authors have no conflicts of interest to disclose.

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Received February 17, 2014

Accepted May 05, 2014

© 2014 by Lippincott Williams & Wilkins