Abstract
Poor Outcomes in a Cohort of HIV-Infected Adolescents
Undergoing Treatment for Multidrug-Resistant
Tuberculosis in Mumbai, India
Petros Isaakidis1*, Roma Paryani1, Samsuddin Khan1, Homa Mansoor1, Mamta Manglani2,
Asmaa Valiyakath1, Peter Saranchuk3, Jennifer Furin4
1Me ́decins Sans Frontie`res, Mumbai, India, 2Pediatric Centre of Excellence for HIV Care, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai,
India, 3Southern Africa Medical Unit, Me ́decins Sans Frontie`res, Cape Town, South Africa, 4Tuberculosis Research Unit, Case Western Reserve University, Cleveland, Ohio,
United States of America
BACKGROUND
Little is known about the treatment of multidrug-resistant tuberculosis (MDR-TB) in HIV-co-infected
adolescents. This study aimed to present the intermediate outcomes of HIV-infected adolescents aged 10–19 years
receiving second-line anti-TB treatment in a Me ́decins Sans Frontie`res (MSF) project in Mumbai, India.
METHOD
A retrospective review of medical records of 11 adolescents enrolled between July 2007 and January 2013 was
undertaken. Patients were initiated on either empirical or individualized second-line ambulatory anti-TB treatment under
direct observation.
RESULTS
The median age was 16 (IQR 14–18) years and 54% were female. Five (46%) adolescents had pulmonary TB (PTB),
two (18%) extrapulmonary disease (EPTB) and four (36%) had both. Median CD4 count at the time of MDR-TB diagnosis was
162.7 cells/ml (IQR: 84.8–250.5). By January 2013, eight patients had final and 3 had interim outcomes. Favourable results
were seen in four (36.5%) patients: one was cured and three were still on treatment with negative culture results. Seven
patients (64%) had poor outcomes: four (36.5%) died and three (27%) defaulted. Three of the patients who died never
started on antiretroviral and/or TB treatment and one died 16 days after treatment initiation. Two of the defaulted died soon
after default. All patients (100%) on-treatment experienced adverse events (AEs): two required permanent discontinuation
of the culprit drug and two were hospitalized due to AEs. No patient required permanent discontinuation of the entire
second-line TB or antiretroviral regimens.
CONCLUSIONS
Early mortality and mortality after default were the most common reasons for poor outcomes in this study.
Early mortality suggests the need for rapid diagnosis and prompt treatment initiation, and adolescents might benefit from
active contact-tracing and immediate referral. Default occurred at different times, suggesting the need for continuous,
intensified and individualized psychosocial support for co-infected adolescents. Operational research among co-infected
adolescents will be especially important in designing effective interventions for this vulnerable group.
