Combating MDR and XDR TB in Rural South Africa
Principal Investigator:
- Gerald Friedland, M.D., Yale University
Co-Investigators:
- Neel Gandhi, M.D., Albert Einstein College of Medicine
- Anthony Moll, M.Sc., M.B.Ch.B., Church of Scotland Hospital, South Africa
- N. Sarita Shah, M.D., M.P.H., Albert Einstein College of Medicine
- Adriaan Willem Sturm, M.D., Ph.D., University of KwaZulu-Natal, South Africa
- Umesh Lalloo, M.D., M.B.Ch.B., University of KwaZulu-Natal, South Africa
Abstract
The global HIV epidemic is fuelling an extraordinary increase in tuberculosis (TB) cases, and in the number of patients co-infected with both diseases. This has most heavily impacted sub-Saharan Africa where the rates of both TB and HIV are highest in the world. We have been performing operations research studies aimed at integrating the care and treatment of TB and HIV in a rural area of the province of KwaZuluNatal, South Africa. Using innovative patient and community support, this strategy has been highly successful in improving the outcome of both diseases. In the course of this work, however, we have recently uncovered and provided the first clinical, epidemiologic and microbiologic reports regarding the presence of a highly prevalent strain of multiple drug resistant tuberculosis (MDR TB) and extensively drug resistant tuberculosis (XDR TB) among HIV co-infected patients. We have found that infection with these organisms is associated with extremely high and rapid mortality. In addition, our studies indicate that there has been recent transmission of these dangerous organisms in both community and hospital settings. Our report of these findings (Lancet 2006) has resulted in widespread and appropriate concern in both the medical and lay communities. Subsequent information has indicated that MDR and XDR TB is widespread in this and other provinces in South Africa and likely in other sub-Saharan African countries. The presence of this and other resistant strains of tuberculosis threaten to further undermine already overwhelmed TB control programs, to blunt the benefit of the introduction of antiretroviral therapy to HIV/TB co-infected populations and to limit the needed integration of HIV/TB diagnosis and treatment.
We propose in this project to develop and evaluate a three part strategy to reduce the prevalence, transmission and consequences of drug resistant tuberculosis among HIV co-infected patients in rural South Africa:
- Earlier diagnosis of MDR and XDR TB, using innovative clinical evaluation and laboratory testing;
- Strengthening and monitoring of infection control practices to reduce hospital associated transmission; and
- Inaugurating community based treatment of drug resistant TB.
This project is based upon and will expand our success in introducing antiretroviral therapy to HIV/TB co-infected patients, and will be undertaken by an established collaborative US and South African research team with investigators at Yale University and Albert Einstein College of Medicine and at a district hospital and NGO, Philanjalo, in rural KwaZulu-Natal, province, the Nelson R. Mandela School of Medicine and Doris Duke Medical Research Institute in Durban and with the support of the KwaZulu-Natal Department of Health. The proposed project has potential for benefit both at the local level in KwaZulu-Natal and in the many resource limited settings worldwide where TB and HIV are highly prevalent.