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TUBERCULOSIS MORTALITY, DRUG RESISTANCE, AND INFECTIOUSNESS IN PATIENTS WITH AND WITHOUT HIV INFECTION IN PERU

The effects of HIV co-infection and multi-drug resistant tuberculosis (MDRTB) on tuberculosis prognosis are poorly defined. Therefore, we studied infectiousness and mortality of 287 tuberculosis patients treated with standard, directly observed, short-course therapy in the Peruvian community. During 6–17 months of treatment, 49 (18%) of patients died, of whom 48 (98%) had AIDS and 28 (57%) had MDRTB; 17/31 (55%) of MDRTB-patients with AIDS died within 2 months of diagnosis, before traditional susceptibility testing would have identified their MDRTB. Most non-MDRTB became smear- and culture-negative within 6 weeks of therapy, whereas most MDRTB remained sputum-culture-positive until death or treatment completion. HIV-negative patients with non-MDRTB had good outcomes. However, MDRTB was associated with prolonged infectiousness and HIV co-infection with early mortality, indicating a need for greater access to anti-retroviral therapy. Furthermore, early and rapid tuberculosis drug-susceptibility testing and infection control are required so that MDRTB can be appropriately treated early enough to reduce mortality and transmission.

Received March 1, 2006. Accepted for publication June 14, 2006.

Acknowledgments: We are grateful to Maria Prado at Maria Auxiliadora Hospital and Nurys Cabanillas, Dr. Jorge Arevalo, and Dr. Marcos Ñavincopa at Dos de Mayo Hospital; to Dr. Lawrence Moulton for statistical assistance; to Dr. David AJ Moore for editorial assistance; and to Patricia Fuentes for laboratory assistance. We gratefully acknowledge the Peruvian Ministry of Health for approval of and collaboration in this project.

Financial support: This research was supported by Wellcome Trust fellowships in Clinical Tropical Medicine (to A.R.E. & C.A.E.); USAID TB Award (HRN-5986-A-00-6006-00); Fogarty-NIH AIDS Training Program (3T22-TW00016-05S3); NIH ITREID (grant 5D43-TW00910); and NIAID (01637).

Conflict of Interest: All authors declare that they have no conflict of interest in relation to this work. Dr. Eduardo Ticona was previously head of the Peruvian National Tuberculosis Control Program.

Disclaimer: The opinions and assertions made by the authors do not reflect the official position or opinion of the U.S. Department of the Army, or the Henry M. Jackson Foundation Inc., or any other organization listed.

^* Address correspondence to Carlton Evans, Department of Infectious Diseases & Immunity and Wellcome Centre for Clinical Tropical Medicine, Imperial College London Hammersmith Hospital Campus, 150 Du Cane Road, London W12 0NN, U.K. E-mail: carltonevans{at}yahoo.com

Authors’ addresses: Vivian K. Kawai, Giselle Soto, and Marco Tovar, Asociacion Benefica Prisma, Av. Carlos Gonzales, Nro. 251, Urbanizacion Maranga, San Miguel, Lima 32, Peru, Telephone and fax, +51 1 464 0221. Robert H. Gilman, Johns Hopkins Bloomberg School of Public Health, Department of International Health, Rm. w5515, 615 N. Wolfe St., Baltimore, MD 21205, Telephone, +1 410 614 3639 or +1 410 614 3959, Fax +1 410 614 6060. Christian T. Bautista (present affiliation), Department of Epidemiology and Threat Assessment, U.S. Military HIV Research Program and the Henry M. Jackson Foundation, 1 Taft Court, Suite 250, Rockville, MD 20850, E-mail: cbautista{at}hivresearch.org. Luz Caviedes, Laboratorio de Investigacion y Desarollo, Departamento de Microbiologia, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martin de Porras, Lima, Peru, Telephone +51 1 483 2942, Fax +51 1 482 4541. Eduardo Ticona, Luz Huaroto, and Victor Chavez, Hospital Dos de Mayo, Av. Grau Cdr. 13 s/n (Parque de la Medicina Peruana), Lima, Peru, Telephone +51 1 328 1414, Fax +51 1 446-1323. Jaime Ortiz and Richard Rodriguez, Hospital María Auxiliadora, Av. Miguel Iglesias 968, San Juan de Miraflores, Lima, Peru, Telephone +51 1 466 5556 or +51 1 466 5455, Fax +51 1 251 3372. A. Roderick Escombe and Carlton A. Evans, Department of Infectious Diseases & Immunity and Wellcome Centre for Clinical Tropical Medicine, Imperial College London, Hammersmith Hospital Campus, 150 Du Cane Road, London W12 0NN, U.K., Fax: +44 20 8383 3394, E-mail: carltonevans{at}yahoo.com.

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