Date: 1 February 2015
Authors: Loveday, M. 1 ; Wallengren, K. 2; Brust, J. 3 ; Roberts, J. 4; Voce, A. 5 ; Margot, B. 6 ; Ngozo, J. 6 ; Master, I. 7 ; Cassell, G. 8 ; Padayatchi, N. 9 ;
Publisher: International Union Against Tuberculosis and Lung Disease
ABSTRACT:
SETTING: KwaZulu-Natal, South Africa, a predominantly rural province with a high burden of tuberculosis (TB), multidrug-resistant TB (MDR-TB) and human immunodeficiency virus (HIV) infection.
OBJECTIVE: To determine the most effective care model by comparing MDR-TB treatment outcomes at community-based sites with traditional care at a central, specialised hospital.
DESIGN: A non-randomised observational prospective cohort study comparing community-based and centralised care. Patients at community-based sites were closer to home and had easier access to care, and home-based care was available from treatment initiation.
RESULTS: Four community-based sites treated 736 patients, while 813 were treated at the centralised hospital (total = 1549 patients). Overall, 75% were HIV co-infected (community: 76% vs. hospitalised: 73%, P = 0.45) and 86% received antiretroviral therapy (community: 91% vs. hospitalised: 82%, P = 0.22). On multivariate analysis, MDR-TB patients were more likely to have a successful treatment outcome if they were treated at a community-based site (adjusted OR 1.43, P = 0.01). However, outcomes at the four community-based sites were heterogeneous, with Site 1 demonstrating that home-based care was associated with an increased treatment success of 72% compared with success rates of 52–60% at the other three sites.
CONCLUSION: Community-based care for MDR-TB patients was more effective than care in a central, specialised hospital. Home-based care further increased treatment success.
Keywords: HIV; models of care; outcomes
Affiliations: 1: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa 2: TB and HIV Investigative Network (Think), Durban, South Africa 3: Department of Medicine, Montefiore Medical Center & Albert Einstein College of Medicine, New York, New York, USA 4: Centers for Disease Control and Prevention, Atlanta, Georgia, USA 5: Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa 6: KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa 7: King Dinuzulu Hospital, Durban, South Africa 8: Harvard University School of Medicine, Boston, Massachusetts, USA 9: Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
