3.4 Drug-resistant TB treatment

Treatment for people diagnosed with rifampicin-resistant TB (RR-TB), isoniazid-resistant TB and multidrug-resistant TB (MDR-TB, defined as resistance to isoniazid and rifampicin) requires regimens that include second-line drugs, such as bedaquiline and fluoroquinolones; these regimens are more expensive (≥US$ 1000 per person) and cause more side-effects than first-line treatments for drug-susceptible TB (1). Pre-extensively drug-resistant TB (pre-XDR-TB, defined as TB that is resistant to rifampicin and any fluoroquinolone) and XDR-TB (resistance to rifampicin, any fluoroquinolone and at least one of bedaquiline or linezolid) are even harder to treat.

Globally in 2020, 150 359 people were enrolled on treatment for MDR/RR-TB, down 15% from 177 100 in 2019. Most of those enrolled on treatment were adults (Fig. 3.4.1). There was considerable country variation in treatment enrolment between 2009 and 2020 (Fig. 3.4.2).

The cumulative total number of people reported as enrolled on treatment for MDR/RR-TB from 2018 to 2020 was 482 683, only 32% of the 5-year target (2018-2022) of 1.5 million that was set at the UN high-level meeting on TB in 2018 (Fig. 3.4.3). For children specifically, the cumulative number was 12 219, only 11% of the 5-year target of 115 000.

Substantial improvements in treatment coverage at the global level require an intensification of efforts to diagnose and treat MDR/RR-TB. This requires one or more of the following to be increased:

• the proportion of people with TB who are detected and, of these, the proportion for whom TB is bacteriologically confirmed;
• the proportion of people with bacteriologically confirmed TB who are tested for drug resistance; and
• the proportion of people diagnosed with MDR/RR-TB who are enrolled in treatment.

Globally in 2018 (the latest patient cohort for which data are available), the treatment success rate for people treated for MDR/RR-TB with second-line regimens was 59%; this has improved steadily in recent years, from 50% in 2012 (Fig. 3.4.4). Among WHO regions, the treatment success rate in 2018 ranged from 56% in the European Region to 69% in the African Region (Fig. 3.4.5).

By the end of 2020, 109 countries were using bedaquiline as part of treatment for drug-resistant TB (DR-TB), 90 were using all-oral longer regimens for the treatment of MDR/RR-TB and 65 were using shorter regimens for the treatment of MDR/RR-TB (Fig. 3.4.6, Fig. 3.4.7, Fig. 3.4.8). At least some people diagnosed with DR-TB were being monitored for adverse events in most countries (Fig. 3.4.9).

Country-specific details about treatment for drug-resistant TB are available in the Global tuberculosis report app and country profiles.

Fig. 3.4.1 The global number of people reported to have been enrolled on treatment for MDR/RR-TB, 2015–2020

Global data disaggregated by age are not available for the years before 2018.

Fig. 3.4.2 Number of MDR/RR-TB cases detected (blue) and enrolled on MDR-TB treatment (red), 2010–2020, 30 high MDR-TB burden countries

Fig. 3.4.3 Global progress in the number of people treated for MDR/RR-TB between 2018 and 2020, compared with cumulative targets set for 2018–2022 at the UN high-level meeting on TB

Fig. 3.4.4 Treatment outcomes for MDR/RR-TB cases globally 2012–2018

Fig. 3.4.5 Treatment outcomes for MDR/RR-TB cases started on treatment in 2018, WHO regions and globally

Fig. 3.4.6 Countries that used bedaquiline for the treatment of MDR/XDR-TB as part of expanded access, compassionate use or under normal programmatic conditions by the end of 2020

Fig. 3.4.7 Countries that used all-oral longer MDR-TB treatment regimens by the end of 2020

Fig. 3.4.8 Countries that used all-oral shorter MDR-TB treatment regimens by the end of 2020

Fig. 3.4.9 Number of patients with active follow up of adverse events as a proportion of patients enrolled on treatment for drug-resistant TB, 2020