Abstract
Background
Globally, case detection and treatment access are poor for rifampicin-resistant tuberculosis (RR-TB). Xpert MTB/Rif has the potential to increase detection and reduce time to treatment (TTT). However, these benefits are dependent on health system capacity to provide treatment.
Methods
We retrospectively assessed the impact of Xpert on treatment initiation and TTT in the context of decentralized RR-TB care in Khayelitsha, Cape Town, using routine programmatic data. Community-based treatment was introduced progressively from 2008. Before 2007, diagnosis relied on phenotypic resistance (culture). Across 2007-08, the line probe assay (LPA) was introduced, followed by Xpert in 2012.
Results
Before decentralization (2003-06) median TTT was 71 days (IQR 49-134, n=158). LPA introduction across 2007-08 was associated with reduced median TTT from 76 to 50 days (p<0.0001, n=257). Between January 2009 and June 2013, 938 RR-TB cases were diagnosed (74% HIV-infected). Decentralization across 2008-11 was associated with declining TTT (p<0.0001, test for trend), to 28 days in 2011 (IQR 16-40, n=173). Xpert was associated with a further reduction to 8 days in 2013 (IQR 5-25, n=89, p<0.0001). Treatment initiation remained unchanged with Xpert and was lower among HIV infected (2010-13); 87.9% (445/506) compared to 96.9% (188/194) for HIV-uninfected (p<0.0001).
Conclusions
Improved case detection and rapid treatment initiation are required to interrupt transmission and reduce mortality. In this setting, decentralization was associated with high treatment initiation and reduced TTT. Xpert implementation significantly enhanced the reduction in TTT and has the potential to reduce transmission.
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Source: Open Forum Infectious Disease