Impact of patient and program factors on default during treatment of multidrug-resistant tuberculosis.

MULTIDRUG-RESISTANT tuberculosis (MDR-TB) is a global problem, with an estimated 440 000 new cases and 150 000 deaths in 2008.1 In the Philippines, approximately 5000 new patients with MDR-TB occur annually, representing about 4% of all new and 21% of retreatment cases.2 Treatment for MDR-TB is complex, involving extended treatment with toxic and less effective second-line drugs. Although most MDR-TB patients can be cured, many default, defined as missing at least 2 consecutive months of treatment during treatment.3 Patients who default or fail treatment are at increased risk for amplified drug resistance, leaving few treatment options. These patients are also prone to increased morbidity and mortality from TB, and contribute to transmission of drug-resistant TB in the community. In 2000, the Tropical Disease Foundation (TDF), a non-government organization (NGO) in collaboration with the Department of Health (DOH), initiated a program to treat patients with MDR-TB, based at the Makati Medical Center (MMC) in Metro Manila, capital of the Philippines. During the first 3 years, default rates were high, averaging 11.4%.4 In response, starting in 2003, TDF implemented several measures to increase treatment adherence. Support included provision of food baskets, housing and transportation allowances, ancillary drugs to manage adverse events and hospitalization support when necessary. A clinic staff member was assigned to monitor patients for treatment interruptions and conduct home visits to optimize treatment adherence. Patient care was decentralized to community facilities, including faith-based organizations, public health centers and NGOs, once a patient had an initial conversion to a negative sputum culture. In this study, we evaluated the association between patients’ socio-demographic and clinical characteristics and the impact of programmatic patient support measures on risk for treatment default among patients treated for MDR-TB between 1999 and 2006.