Multidrug Resistant Tuberculosis (MDR-TB) in India

MDR-TB is a form of tuberculosis where the bacteria are resistant to rifampicin and isoniazid, two essential drugs in TB treatment. This form of TB carries a high risk of death, estimated at 30-40%. India has a significant burden of TB, contributing 27% of the 1,75,923 MDR-TB cases reported globally in 2023.

Challenges in Treatment

• The evolution of MDR-TB strains is often due to poor adherence to TB treatment and misuse of drugs, common in India.
• Traditional treatments for drug-resistant TB are lengthy (18 months or more) and involve toxic drugs, posing adherence challenges.
• Patients have long advocated for shorter and less toxic treatment regimens, which were often ignored by the health system.
• Side effects from treatments, such as hearing loss and depression, were often downplayed, exacerbating the stigma and discomfort for patients.

New Treatment Regimens

There is a need for shorter regimens to improve treatment completion rates and reduce economic burdens. The BPaL regimen, consisting of bedaquiline, pretonamid, and linezolid, is one such example, prescribed for 6 months.

• The Nix-TB trial in South Africa demonstrated the regimen's efficacy, and the ZeNix trial showed better tolerance with reduced linezolid doses.
• Although promising, adherence and drug-susceptibility testing are crucial for these new regimens.
• Adverse effects, such as sensory neuropathy from linezolid, need monitoring, and alternative regimens should be available.

Health System and Implementation

• Adequate training for physicians on managing these regimens is essential.
• Universal molecular diagnostics are needed to detect drug-resistant TB early.
• Effective public-private partnerships can improve access while preventing misuse of treatments.

Additional Considerations

• Shorter regimens might be costlier, but persisting with toxic alternatives is more detrimental.
• Community education and supportive services such as counseling are key to successful implementation.
• Addressing social, economic, and gender determinants is crucial for a holistic TB control approach.

Conclusion

While shorter regimens for MDR-TB are transformative, they are not sufficient alone. A broader systemic transformation addressing structural determinants is necessary for effective TB control.