Management of multidrug-resistant tuberculosis with shorter treatment regimen in Niger: Nationwide programmatic achievements

Background: In Niger, the Shorter Treatment Regimen (STR) has been implemented nationwide for rifampicin resistant tuberculosis (RR-TB), since 2008. No previous publication has shown the results from countrywide programmatic implementation using few exclusion criteria, nor exhaustively assessed the effect of initial resistance to companion drugs on outcomes. Methods: The National Tuberculosis Programme and the Damien Foundation conducted a retrospective observational study to evaluate the management of RR-TB from 2008 to 2016. Baseline resistance to drugs was assessed phenotypically, complemented by screening the inhA, katG and pncA genes. Cured patients were followed-up for a period of one year after cure. Findings: Among 1044 patients tested for rifampicin resistance, mainly previously treated patients, 332 were diagnosed with pulmonary RR/TB, 288 were enrolled on treatment and 255 started on STR. Six patients received a modified STR. Among 249 patients on standardised STR, 207 (83.1%) were cured relapse-free, eight (3.2%) had failure, 23 (9.2%) died, seven (2.8%) were lost to follow-up and four (1.6%) relapsed. The risk of unfavourable outcome was higher in patients with initial resistance to fluoroquinolones (aOR 20.4, 95%CI:5.6-74.6) and very severely underweight (aOR 3.9, 95%CI:1.5-10.1). Successful outcome was not affected by initial resistance to companion drugs. Serious ototoxicity was reported in eight patients (3.2%). Interpretation: A comprehensive nationwide approach to multidrug-resistant tuberculosis management using the STR was feasible and successful. Outcomes were not affected by initial resistance to companion drugs. Our study confirms the effectiveness and safety of the STR.