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Treatment Adherence Among Persons Receiving Concurrent Multidrug-Resistant Tuberculosis and HIV Treatment in KwaZulu-Natal, South Africa

Stephens, Fay MPHa; Gandhi, Neel R. MDa; Brust, James C.M. MDb; Mlisana, Koleka MBChB, PhDc; Moodley, Pravi MD, MBChBd; Allana, Salim MD, MPHa; Campbell, Angie MAa; Shah, Sarita MD, MPHa,e

JAIDS Journal of Acquired Immune Deficiency Syndromes: October 1, 2019 - Volume 82 - Issue 2 - p 124–130
doi: 10.1097/QAI.0000000000002120
Epidemiology
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Background: Success in multidrug-resistant tuberculosis (MDR-TB) and HIV treatment requires high medication adherence despite high pill burdens, frequent adverse events, and long treatment duration, which may jeopardize adherence. We prospectively compared MDR-TB/HIV-coinfected persons to those with MDR-TB alone to determine the impact of concurrent treatment on adherence and outcomes.

Methods: We assessed medication adherence monthly using 3-day recall, 30-day recall, and visual analog scale and examined adherence to monthly study visits (months 0–12). We determined the proportion of participants fully adherent (no reported missed doses) to MDR-TB vs. HIV treatment by each measure. We assessed the association of medication and clinic visit adherence with MDR-TB treatment success (cure or completion, 18–24 months) and HIV virologic suppression.

Results: Among 200 patients with MDR-TB, 63% were women, median age was 33 years, 144 (72%) were HIV-infected, and 81% were receiving antiretroviral therapy (ART) at baseline. Adherence to medications (81%–98% fully adherent across all measures) and clinic visits (80% missed ≤1 visit) was high, irrespective of HIV status. Adherence to ART was significantly higher than to MDR-TB treatment by all self-reported measures (3-day recall: 92% vs. 84%, respectively; P = 0.003). In multivariable analysis, the adjusted risk ratio of unsuccessful MDR-TB treatment increased with every missed visit: 1.50, 2.25, and 3.37 for unsuccessful treatment, for 1, 2, and ≥3 missed visits.

Conclusions: Adherence to ART was higher than to MDR-TB treatment among persons with MDR-TB/HIV coinfection. Missed clinic visits may be a simple measure for identifying patients at risk of unsuccessful MDR-TB treatment outcome.

aDepartment of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA;

bDivisions of General Internal Medicine & Infectious Diseases, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY;

cDepartment of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal and National Health Laboratory Service, Durban, South Africa;

dDepartment of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal and National Health Laboratory Service, Durban, South Africa; and

eDivision of Global HIV and Tuberculosis, US Centers for Disease Control and Prevention, Atlanta, GA.

Correspondence to: Neel R. Gandhi, MD, Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, CNR 3031, Atlanta, GA 30306 (e-mail: neel.r.gandhi@emory.edu).

Supported by the US National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH; R01AI087465 and R01AI089349, both to N.R.G.). It was also supported in part by grants from NIH/NIAID to J.C.M.B. (K23AI083088, R01AI114304), N.R.G. (K24AI114444), the Emory University TB Research Unit (U19AI111211) and CFAR (P30AI050409), Albert Einstein College of Medicine (CFAR P30AI124414), Albert Einstein College of Medicine and Montefiore Medical Center ICTR (UL1TR001073), and the Atlanta CTSI (UL1TR000454).

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention, US National Institutes of Health, or the US Department of Health and Human Services.

The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jaids.com).

Received March 19, 2019

Accepted May 29, 2019

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.