In February 2009, GHC and the Ethiopian FMOH initiated a treatment programme for MDR TB in Ethiopia at St. Peter's Hospital in Addis Ababa. The second site was initiated in September 2010 at the University of Gondar Hospital (UoG) in Gondar, northwestern Ethiopia. Clinical staff involved in programme start-up first received didactic training in Addis Ababa and hands-on training in Cambodia from GHC and ongoing clinical mentorship. This group formed the key participants in the Ethiopian MDR Technical Working Group.
All patients with MDR TB, defined as having evidence of resistance to isoniazid and rifampicin by phenotypic drug-susceptibility testing or genotypic resistance by a line probe assay (GenoType MTBDRplus V.2.0, HAIN Life Science, Nehren, Germany), were eligible to receive treatment. Additionally, patients with rifampicin-monoresistance or those with clinically presumed MDR TB, based on multiple treatment failures despite directly observed therapy (DOT), or those who were close contacts of patients with MDR TB, were also eligible for treatment. A standardised, second-line drug (SLD) regimen was administered, consisting of (1) at least three oral agents to which the patient was presumed to have susceptibility (eg, levofloxacin, ethionamide, cycloserine or para-aminosalicyclic acid (PAS)), (2) pyrazinamide and (3) an aminoglycoside (amikacin or kanamycin) or polypeptide (capreomycin) injectable agent. Injectables were maintained for a minimum of 8 months based on clinical, microbiological and radiographic evolution, and ultimate treatment duration was a minimum of 18 months after bacteriological conversion.
Most patients were hospitalised at the initiation of therapy in accordance with national standards until they smear converted and were clinically stable, followed by transition to the ambulatory setting. A subset of healthier patients was initiated on therapy as outpatients beginning in 2010. After discharge from the hospital, patients returned to the hospital outpatient clinic on a monthly basis and visited health centres in their proximity for daily drug administration and observation. Monthly sputum samples were collected for both inpatients and outpatients for smear and mycobacterial culture.
Family treatment supporters were trained for drug adherence monitoring, and those patients living within Addis Ababa and Gondar were visited monthly at home by a dedicated outpatient team. All patients received a monthly food basket. After assessment of the patient's living conditions, those found to be vulnerable due to extreme poverty were provided economic assistance for transport, additional food and house rent if needed throughout therapy. Patients who were initiated on therapy as outpatients were followed by the GHC outpatient team, including roving nurses who provided them with daily injections of the injectable agent (5–6 days per week). All patients were screened for HIV upon enrolment. Patients who were HIV-infected were offered antiretroviral therapy (ART) regardless of CD4 cell count if not on ART prior to enrolment, or were continued on ART, if on this treatment already.
All patients with MDR TB, defined as having evidence of resistance to isoniazid and rifampicin by phenotypic drug-susceptibility testing or genotypic resistance by a line probe assay (GenoType MTBDRplus V.2.0, HAIN Life Science, Nehren, Germany), were eligible to receive treatment. Additionally, patients with rifampicin-monoresistance or those with clinically presumed MDR TB, based on multiple treatment failures despite directly observed therapy (DOT), or those who were close contacts of patients with MDR TB, were also eligible for treatment. A standardised, second-line drug (SLD) regimen was administered, consisting of (1) at least three oral agents to which the patient was presumed to have susceptibility (eg, levofloxacin, ethionamide, cycloserine or para-aminosalicyclic acid (PAS)), (2) pyrazinamide and (3) an aminoglycoside (amikacin or kanamycin) or polypeptide (capreomycin) injectable agent. Injectables were maintained for a minimum of 8 months based on clinical, microbiological and radiographic evolution, and ultimate treatment duration was a minimum of 18 months after bacteriological conversion.
Most patients were hospitalised at the initiation of therapy in accordance with national standards until they smear converted and were clinically stable, followed by transition to the ambulatory setting. A subset of healthier patients was initiated on therapy as outpatients beginning in 2010. After discharge from the hospital, patients returned to the hospital outpatient clinic on a monthly basis and visited health centres in their proximity for daily drug administration and observation. Monthly sputum samples were collected for both inpatients and outpatients for smear and mycobacterial culture.
Family treatment supporters were trained for drug adherence monitoring, and those patients living within Addis Ababa and Gondar were visited monthly at home by a dedicated outpatient team. All patients received a monthly food basket. After assessment of the patient's living conditions, those found to be vulnerable due to extreme poverty were provided economic assistance for transport, additional food and house rent if needed throughout therapy. Patients who were initiated on therapy as outpatients were followed by the GHC outpatient team, including roving nurses who provided them with daily injections of the injectable agent (5–6 days per week). All patients were screened for HIV upon enrolment. Patients who were HIV-infected were offered antiretroviral therapy (ART) regardless of CD4 cell count if not on ART prior to enrolment, or were continued on ART, if on this treatment already.
