ArticlesFeasibility and cost-effectiveness of standardised second-line drug treatment for chronic tuberculosis patients: a national cohort study in Peru
Introduction
Multidrug-resistant (MDR) tuberculosis-ie, resistance to at least rifampicin and isoniazid-is a threat to tuberculosis control efforts in some countries.1, 2 Patients with MDR tuberculosis often do not respond to short-course chemotherapy with first-line drugs.3 Thus, treatment with second-line drugs may be needed to cure these individuals and to curtail transmission of such strains of Mycobacterium tuberculosis. However, data from low-income or middle-income countries on the management of MDR tuberculosis with second-line drugs under programme conditions are not available. As a result, international public-health institutions, including the WHO, do not have definitive policy recommendations in place; guidelines exist only for specialised centres where resources that permit treatment are available.4 Treatment of MDR tuberculosis is, however, available in more-developed countries.5, 6
After results of a survey of drug-resistant tuberculosis showed an MDR prevalence of 16% among previously treated individuals,1 Peru's National Tuberculosis Programme introduced a standardised treatment regimen, including second-line drugs, for patients who had failed to respond to standard treatment with first-line drugs. Our aim was to assess the feasibility, effectiveness, affordability, and cost-effectiveness of implementing such treatment services.
Section snippets
Setting
Peru is a middle-income country that had a per capita Gross National Income of US$2390 in 1999.7 The DOTS strategy was introduced in 1991 and is now implemented in all health facilities.8, 9 WHO targets for tuberculosis control (70% case detection and 85% cure rate among new smear-positive pulmonary cases) have been achieved and sustained, as a result of which the incidence rate is declining at an estimated 6% per year.9
Before 1997, the treatment policy in Peru was limited to short-course
Baseline characteristics and monitoring of participants
During enrolment, the committee assessed 755 requests to treat tuberculosis cases with second-line drugs; 477 (63%) were accepted. 21 of 34 health departments in Peru enrolled patients. 11 (2%) of the enrolled patients were excluded from our analysis; reasons included use of a non-standardised treatment regimen, and unfinished treatment. Table 2 shows demographic characteristics according to entry criteria. Susceptibility test results were available for 344 (74%) patients. 335 (97%) individuals
Discussion
These data from Peru provide evidence with respect to the feasibility and cost-effectiveness of providing standardised second-line drug treatment for chronic tuberculosis patients among whom MDR prevalence is high, under programme conditions and on a national basis, in a middle-income country. They show that Peru's National Tuberculosis Programme was able to achieve a compliance rate of nearly 90%, a cure rate of almost 50% among all patients enrolled, and a cure rate of 63% among those who
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