Hindawi Publishing Corporation

Tuberculosis Research and Treatment

Volume 2016, Article ID 1468631, 7 pages
http://dx.doi.org/10.1155/2016/1468631

Research Article
Characteristics and Treatment Outcomes of
Retreatment Tuberculosis Patients in Benin
Serge Ade,1,2,3 Omer Adjibod,1 Prudence Wachinou,1
Narcisse Toundoh,1 Brnice Awanou,1 Gildas Agodokpessi,1 Dissou Affolabi,1
Gabriel Ad,1 Anthony D. Harries,3,4 and Sverin Anagonou1
1

National Tuberculosis Programme, 01 BP 321 Cotonou, Benin

Faculte de Medecine, Universite de Parakou, Parakou, Benin
3
International Union against Tuberculosis and Lung Disease, Paris, France
4
London School of Hygiene & Tropical Medicine, London, UK
2

Correspondence should be addressed to Serge Ade; [email protected]

Received 30 December 2015; Accepted 9 March 2016
Academic Editor: Isamu Sugawara
Copyright 2016 Serge Ade et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. To determine among retreatment tuberculosis patients in Benin baseline characteristics, culture, and drug sensitivity
testing (DST) results and treatment outcomes. Materials and Methods. A retrospective national cohort study of all retreatment
tuberculosis patients in Benin in 2013 using registers and treatment cards. Results. Of 3957 patients with tuberculosis, 241 (6%)
were retreatment cases. Compared to new pulmonary bacteriologically confirmed tuberculosis (NPBCT) patients, there were
significantly higher numbers of males ( = 0.04), patients from Atlantique-Littoral ( = 0.006), patients aged 4564 years
( = 0.007), and HIV-positive patients ( = 0.04) among those retreated. Overall, 171 (71%) patients submitted sputum for DST,
of whom (163) 95% were positive for Mycobacterium tuberculosis on Xpert MTB/RIF and/or culture and 17 (10%) were rifampicin
resistant (9 with MDR-TB and 8 monoresistant to rifampicin). For those without MDR-TB ( = 224), treatment success was 93%.
Worse outcomes occurred in those with unknown HIV status (RR: 0.27; 0.051.45; < 0.01) while better outcomes occurred in
those who relapsed (RR: 1.06, 95 CI: 1.021.10, = 0.04). Conclusion. In 2013, a high proportion of retreatment patients received
DST. Treatment success was good although more needs to be done to systematically increase the final follow-up smear examination.
Reasons of high losses to follow-up from Oueme-Plateau should be investigated.

1. Introduction
Patients with retreatment tuberculosis (TB) represent those
who have been treated previously for one month or more with
anti-TB drugs and who have been diagnosed once again with
the disease. These patients mainly include relapses, treatment
after failure, or loss to follow-up on a first-line treatment
regimen [1]. The number of these patients is not negligible.
In 2014, of the 6.3 million TB cases that were notified
by National TB Programmes (NTPs) to the World Health
Organization (WHO), approximately 700,000 patients were
already previously treated [2].
Interest in this category of TB comes from the fact that
patients are known to have a higher risk of drug resistance

compared with new cases. Therefore, in addition to recommendations that all TB patients be screened for Human
Immunodeficiency Virus (HIV) coinfection, NTPs have been
advised since 2010 by WHO to systematically test at diagnosis
all retreatment TB patients for culture and drug susceptibility
(DST with genotypic and/or phenotypical methods), in order
to detect resistance to rifampicin which is usually synonymous with multidrug resistance (MDR, strictly defined as
resistance of Mycobacterium tuberculosis to both rifampicin
and isoniazid) [3, 4]. Unfortunately, there is concern about
implementation of this recommendation as only 58% of all
retreatment TB patients in the world were tested for drug
resistance in 2014 [2]. Improving this proportion in the future
requires an analysis of the situation at country levels.

2
In Benin, a sub-Saharan country that reports approximately 40 incident TB cases per 100,000 people per year,
retreatment patients account for less than 10% of all notified
TB cases. Unfortunately, there is dearth of information
on the epidemiological characteristics and HIV status of
these patients in annual reports in the country [5]. Two
previous studies, which were only conducted in Cotonou,
the economic capital, and which had included retreatment
patients diagnosed in the periods of 19922001 and 2005
2009, respectively, reported a high loss to follow-up of 12%,
with a treatment success of retreatment cases significantly
lower than new cases. Moreover, the majority of these patients
recorded as loss to follow-up during the retreatment initially had also defaulted from their first-line treatment [6, 7].
DST in retreatment cases was also only performed in early
2003 in those patients registered in Cotonou that also houses
the Laboratoire de Reference des Mycobacteries (LRM).
The current study was therefore undertaken in the whole
country to determine the principal characteristics of retreatment patients, to assess how well DST was performed in
this category of patients and whether there was any change
in their treatment outcomes. Specific objectives were to
determine among retreatment TB patients diagnosed and
treated in 2013 in Benin: (i) the epidemiological, clinical and
geographical characteristics and HIV status of these patients
and compared to those registered with New Pulmonary
Bacteriologically Confirmed TB (NPBCT); (ii) the proportion with DST results available along with the proportion
showing resistance to rifampicin; (iii) treatment outcomes of
these patients compared with NPBCT cases; and (iv) factors
associated with a successful treatment outcome.

2. Materials and Methods

2.1. Study Design. This was a retrospective cohort study using
routinely collected data.
2.2. General Setting and Study Sites
Country. Benin is a small low-income country in West Africa
with a population of 10,315,244 inhabitants in 2015 [8]. The
country shares borders with Burkina Faso and Niger in the
north, Togo in the west, and Nigeria in the east. Benin is a
low-income country with a gross national income per capita
of US$1780 in 2013 and an under-five mortality rate of 85 per
1000 live births [9].
National TB Programme & Management of Patients with a
Previous History of TB. The country follows the WHO DOTS
strategy for diagnosis and treatment of TB patients [4]. All
patients with a previous history of TB and who return to the
health facility for presumptive symptoms of the disease are
requested to provide two sputum samples on two consecutive
days for acid-fast bacilli microscopy. Sputum samples are
routinely examined using auramine-phenol staining and
fluorescence microscopy. The diagnosis is confirmed by a
positive result for acid-fast bacilli on sputum smears. Sputa of
all confirmed retreatment TB cases in the 57 Basic Management Units (BMUs) are then sent by laboratory technicians

Tuberculosis Research and Treatment

using cetylpyridinium chloride solution to the LRM for both
Xpert MTB/RIF and culture on Lowenstein-Jensen media. All
retreatment TB patients, except those diagnosed in Cotonou,
start on a standardised regimen of retreatment [3]. When
the result of Xpert MTB/RIF is available (this usually takes
some days or weeks), those who are found sensitive to
rifampicin continue the standardised regimen. On the other
hand, patients with resistance to rifampicin are switched to a
MDR-TB treatment regimen.
Because of the closeness of the LRM, patients treated
in Cotonou do not start TB treatment unless their Xpert
MTB/RIF is available. This takes approximately 24 hours.
The standardised retreatment regimen consists of an initial
phase of rifampicin, isoniazid, ethambutol, and pyrazinamide
for 3 months (with streptomycin added during the first 2
months) followed by a continuation phase using the first
three anti-TB drugs for 5 months [3]. The treatment is strictly
directly observed during the initial phase. Patients with
resistance to rifampicin are treated with a shortened 9-month
regimen recommended by the International Union against
Tuberculosis and Lung Disease [10]. During retreatment of
rifampicin sensitive patients, sputum samples are collected
at 3 months, at 5 months, and at the end of the treatment
for microscopy. Treatment is monitored through the use of
treatment cards and registers. A quarterly supervision of all
the 57 BMUs is systematically organized by the TB control
programme coordination. All retreatment TB patients are
systematically offered HIV testing at diagnosis. Those who are
found coinfected receive co-trimoxazole, and Antiretroviral
Therapy (ART) is provided within 2 weeks to 2 months after
TB treatment initiation [11].
All molecular tests, culture, DST, TB treatment, cotrimoxazole, and ART are provided free of charge. Anti-TB
and ARV drugs are not available in private pharmacies.
2.3. Study Population. All retreatment TB patients diagnosed
and treated between January and December 2013 were
included in the study.
2.4. Data Variables, Sources of Data, Data Collection Tools,
and Definition of Variables. For each retreatment TB case,
data were collected on epidemiological characteristics,
region, HIV status, type of retreatment, ART status for HIVpositive patients, Xpert MTB/RIF results, culture and DST
results, and treatment outcomes. Sources of data were TB registers and TB treatment cards. Xpert MTB/RIF, culture, and
phenotypical DST results were extracted from a laboratory
Excel file. For comparison, aggregate data of NPBCT patients
were collected from the annual report. Data on patients were
collected into a paper based questionnaire. Because of the
retrospective nature of this study, data validation was not
possible. The definitions of the NPBCT, the different types of
previously treated patients, and the treatment and outcomes
are explained in Table 1.
2.5. Analysis and Statistics. Data from the questionnaire were
double entered into an electronic file using EpiData software
and analysed using this software (EpiData version 3.1 for
entry and version 2.2.2.182 for analysis, EpiData Association,

Tuberculosis Research and Treatment

Table 1: New category of patients and treatment outcomes recommended by the WHO [1].
Definitions
Category of TB patients
New pulmonary bacteriologically confirmed patients
Previously treated patients
Relapse patients
Treatment after failure patients
Treatment after loss to follow-up patients
Other previously treated patients
Patients with unknown previous TB treatment history

Patients never treated for TB (or treated for less than 1 month) and whose
sputum is positive by smear microscopy, culture, or WHO-approved Rapid
Diagnostic (such as Xpert MTB/RIF)
Patients have received 1 month or more of anti-TB drugs in the past
Patients have previously been treated for TB, were declared cured or treatment
completed at the end of their most recent course of treatment, and are now
diagnosed with a recurrent episode of TB
Patients have previously been treated for TB and failed treatment during or at
the end of their most recent treatment course
Patients have previously been treated for TB and were declared lost to
follow-up during or at the end of their most recent course of treatment
Patients have previously been treated for TB but their outcome after their
most recent course of treatment is unknown or undocumented
Patients do not fit into any of the categories listed above

Treatment outcomes
Cured

Treatment completed

Treatment failed
Died
Loss to follow-up
Not evaluated
Treatment success

A pulmonary TB patient with bacteriologically confirmed TB at the beginning

of treatment who was smear- or culture-negative in the last month of
treatment and on at least one previous occasion
A TB patient who completed treatment without evidence of failure, but with
no record to show that sputum smear or culture results in the last month of
treatment and on at least one previous occasion were negative, either because
tests were not done or because results were unavailable
A TB patient whose sputum smear or culture is positive at month 5 or later
during treatment
A TB patient who dies for any reason before starting or during the course of
treatment
A TB patient who did not start treatment or whose treatment was interrupted
for 2 consecutive months or more
A TB patient for whom no treatment outcome is assigned; this includes cases
transferred out to another treatment unit as well as cases for whom the
treatment outcome is unknown to the reporting unit
The sum of cured and treatment completed

Odense, Denmark). Data were analysed by using frequencies

and percentages. Comparisons between categorical variables
were done using the chi-square test and risk ratios as appropriate with 95% confidence intervals. Levels of significance
were set at 5%.

3. Results
In 2013, 241 retreatment TB patients were diagnosed and
treated in Benin on the basis of a positive result for acidfast bacilli using sputum smear microscopy. They represented
6% of the 3957 total TB cases notified in the country in
the same time-period. Demographic characteristics and HIV
status of these patients were compared to those reported from
NPBCT and are shown in Table 2. There were significantly
more males ( = 0.04), patients from the AtlantiqueLittoral ( = 0.006), patients aged between 45 and 64
years ( = 0.007), and HIV-positive patients ( = 0.04)
among retreatment TB cases compared to NPBCT patients.
On the other hand, patients younger than 24 years were

significantly less common among previously treated patients

( < 0.001). Demographic characteristics and HIV status
of the different types of retreatment TB cases are compared
in Table 3. Oueme-Plateau reported significantly more
treatment after loss to follow-up cases ( < 0.001) while
Atlantique-Littoral reported more relapse cases ( =
0.04). In addition, significantly more males were found in
treatment after loss to follow-up ( = 0.03). Otherwise, no
significant differences were found.
The results of Xpert MTB/RIF and/or Mycobacterium
tuberculosis culture among retreatment TB patients and
rifampicin sensitivity are presented in Table 4. Overall, 71%
of the 241 retreatment TB patients submitted their sputum for
DST, and 95% of these patients showed a positive result on
Xpert MTB/RIF and/or culture for M. tuberculosis. Of these
patients, 17 (10%) were found to have resistance to rifampicin
(9 with MDR-TB and 8 with monoresistance to rifampicin)
and they were redirected to a MDR-TB treatment regimen.
Treatment outcomes of the remaining 224 retreatment
TB patients were compared with those for NPCBT cases and

Tuberculosis Research and Treatment

Table 2: Demographic characteristics and HIV status of new pulmonary bacteriologically confirmed and retreatment tuberculosis
patients, Benin, 2013.
NPBCT
3129

Total
Sex
Male
2063 (65.9)
Female
1066 (34.1)
Age (years)
0024
600 (19.2)
2544
1705 (54.5)
4564
676 (21.6)
65 and above
148 (4.7)
Region
Atacora-Donga
199 (6.4)
Borgou-Alibori
231 (7.4)
Zou-Collines
416 (13.3)
Mono-Couffo
486 (15.5)
Oueme-Plateau
708 (22.6)
Atlantique-Littoral 1089 (34.8)
HIV status
HIV positive
396 (13.5 )
HIV negative

Unknown

Retreatment TB
241

value

175 (72)
67 (28)

0.04
0.04

21 (8.7)
136 (56.6)
70 (28.9)
14 (5.8)

0.00005
0.55
0.007
0.43

14 (5.8)
13 (5.4)
33 (13.7)
29 (12)
47 (19.5)
105 (43.6)

0.72
0.24
0.86
0.14
0.26
0.006

43 (18.2 )
193 (82)
5 (2.4)

0.04

Note: NPBCT: new pulmonary bacteriologically confirmed tuberculosis. TB:

tuberculosis.

Of the 2934 new pulmonary bacteriologically confirmed tuberculosis

patients who underwent the HIV test, 396 were found positive.

Of the 236 retreatment tuberculosis patients who underwent the HIV test,
43 were found positive.

the results are shown in Table 5. In 2013, the success rate of

these patients was 93%. There were significantly more patients
who completed their treatment without achieving the last
follow-up examination, but otherwise there were no other
differences between the groups. Factors associated with a
successful outcome are presented in Table 6. Patients with
relapse TB had a significantly higher chance of successful
treatment outcome (RR: 1.06, 95 CI: 1.021.10, = 0.04) while
those with an unknown HIV status had a worse treatment
outcome (RR: 0.27; 0.051.45; < 0.01). In this cohort,
in which all but one of the HIV-positive patients were on
ART, no significant difference in treatment success was found
between HIV-positive and HIV-negative patients.

4. Discussion
The main findings of this study were the predominance of
males, adults aged between 45 and 64 years, and HIV-positive
status among retreatment TB cases compared with NPBCT
patients. Most of these previously treated TB patients were
reported from Atlantique-Littoral where there were also
predominately relapse cases. The large majority of patients
who were reported from Oueme-Plateau were recorded as
lost to follow-up prior to treatment, which is a department
close to Atlantique-Littoral in the southern part of the

country. Rifampicin sensitivity-status was known in nearly

three-fourths of patients with one-tenth of those tested having resistance to rifampicin and therefore requiring a MDRTB treatment regimen. Treatment outcomes of patients who
were found without resistance to rifampicin were excellent,
although some did not achieve the last follow-up sputum
smear examination after treatment completion. Patients who
relapsed had a greater chance of a successful treatment
outcome, while those with unknown HIV status had worse
treatment outcomes.
The strengths of this study were the inclusion of all
retreatment TB patients diagnosed in the country, and therefore there was no need for any sampling framework. The
study report also followed Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) guidelines
[12]. Data used for this study had been checked and validated
during regular quarterly supervision of the 57 BMUs from
the central unit. Limitations include the operational nature
of the study and the use of routine data from registers and
quarterly reports. Some information such as time to relapse
after a previous treatment is often missed and therefore could
not be included in the study.
This is the first assessment one year after the NTP coordination decided as a policy to perform DST at diagnosis for all
retreatment cases countrywide. Benefits from the implementation of such a recommendation can be seen from this study.
MDR-TB patients can promptly start appropriate treatment
without having to start and fail a retreatment regimen,
which has individual benefits as well as preventing further
transmission of drug-resistant TB in the community. Studies
from India have also shown that this approach improves
treatment outcomes among previously treated patients [13].
According to our study findings, one-quarter of the patients
did not achieve this goal of DST. The proportion of previously
treated patients in whom DST has been performed largely
varies according to the study settings, from less than 10% in
the midwest Nepal to 91% in Sri Lanka [14, 15].
One of the major challenges in achieving DST for all
patients that arose from discussions with health workers
and that has also been reported elsewhere is related to
transportation issues of samples from laboratories in BMUs
to the LRM. This is a key step for successful implementation of
culture and DST, particularly in resources-limited countries.
In Benin, several options of sample transportation have been
tried. In the first option, sputum specimens once collected
were appropriately packaged in specific boxes in BMUs; and,
during quarterly supervisions, national teams had the opportunity to bring them back to the LRM for analysis with results
communicated later to the TB health workers in the BMUs.
The consequences of this approach, however, were the high
likelihood of having a negative culture due to lengthy times
between sputum collection and the plating of specimens
on Lowenstein-Jensen culture media and the subsequent
delays in diagnosing and treating patients requiring MDRTB treatment. In the second option, laboratory technicians
in BMUs were requested to bring to the LRM specimens
from patients and they were reimbursed for transportation.
Unfortunately the high cost of this option did not allow it to
continue. The third option and the current strategy is to send

Tuberculosis Research and Treatment

Table 3: Demographic characteristics and HIV status of the different types of retreatment tuberculosis patients, Benin, 2013.

Total
Sex
Male
Female
Age (years)
0024
2544
4564
65 and +
Regions
Atacora-Donga
Borgou-Alibori
Zou-Collines
Mono-Couffo
Oueme-Plateau
Atlantique-Littoral
HIV status
HIV positive
HIV negative
Unknown

Relapse
147

Failure
78

Treatment after loss to follow-up

16

value

102 (69.4)
45 (30.6)

56 (71.8)
22 (28.2)

16 (100)

0.03
0.03

10 (6.8)
86 (58.5)
42 (28.6)
9 (6.1)

10 (12.8)
42 (53.8)
22 (28.2)
4 (5.1)

1 (6.3)
8 (50)
6 (37.5)
1 (6.3)

0.29
0.69
0.74

8 (5.4)
7 (4.8)
16 (10.9)
16 (10.9)
27 (18.4)
73 (49.7)

6 (7.7)
6 (7.7)
16 (20.5)
12 (15.4)
10 (12.8)
28 (35.9)

0
0
1 (6.3)
1 (6.3)
10 (62.5)
4 (25)

0.09
0.46
0.00002
0.04

27 (18.4)
116 (78.9)
4 (2.7)

14 (17.9)
63 (80.8)
1 (1.3)

2 (12.5)
14 (87.5)
0

0.84
0.70

Table 4: Retreatment tuberculosis patients, drug susceptibility testing achieved, and bacilli sensitivity to rifampicin, Benin, 2013.
Total retreatment TB patients
Patients whose specimens were sent to the LRM for DST tests ()
MTB identification after culture and or Xpert MTB/RIF
Xpert (+) Culture (+) ()
Xpert (+) Culture () ()
Xpert () Culture (+) ()
Resistance to rifampicin ()

241
171 (71)
163 (95)
86 (50)
72 (42)
5 (3)
17 (10)

Note: TB: tuberculosis; LRM: Laboratoire de References des Mycobacteries; DST: drug susceptibility testing.

The percentage was derived from the total tuberculosis patients retreated.

The percentage was derived from the total tuberculosis patients whose sputa were sent and analysed in LRM.

Of the 17 patients with resistance to rifampicin, there were 9 multidrug resistant and 8 monoresistant.

Table 5: Treatment outcomes of new pulmonary bacteriologically confirmed and retreatment tuberculosis patients, Benin, 2013.

Total
Successful outcome
Cure
Completion
Unsuccessful outcome
Failure
Death
Loss to follow-up
Not evaluated

NPBCT
3124
2803 (89.7)
2587 (82.8)
216 (6.9)
321 (10.3)
91 (2.9)
170 (5.4)
45 (1.4)
15 (0.5)

Retreatment TB
224m
208 (92.9)
184 (82.1)
24 (10.7)
16 (7.1)
3 (1.3)
9 (4)
3 (1.3)
1 (0.4)

Note: TB: tuberculosis.

NPBCT: new pulmonary bacteriologically confirmed tuberculosis.

Of the 3129 new smear positive TB patients treated, treatment outcomes were assessed for 3124 patients in 2013.
m
Of the 241 retreatment tuberculosis patients treated, 18 were found multidrug resistant and did not continue the retreatment regimen.

value
0.12
0.79
0.03
0.13
0.16
0.37
0.83
0.72

Tuberculosis Research and Treatment

Table 6: Factors associated with a successful treatment among retreatment tuberculosis patients, 2013, Benin.

Sex
Female
Male
Age group
0024
2544
4564
65 and +
Type of TB
NPBCT
Relapse
Failure
Treatment after loss to follow-up
HIV status
HIV negative
HIV positive
HIV status unknown
Region
Atacora-Donga
Borgou-Alibori
Zou-Collines
Mono-Couffo
Oueme-Plateau
Atlantique-Littoral

Successful outcome

Risk ratio

[95% CI]

value

60/62 (97.8)
148/162 (91.4)

1
0.94

0.881.01

0.24

19/19 (100)
117/124 (94.4)
60/67 (89.6)
12/14 (85.7)

1
0.94
0.90
0.86

0.900.99
0.830.97
0.691.06

0.59
0.34
0.17

2803/3124 (89.7)
133/140 (95)
63/69 (91.3)
12/15 (80)

1
1.06
1.02
0.89

1.021.10
0.951.10
0.691.15

0.04
0.67
0.19

169/181 (93.4)
38/39 (97)
1/4 (25)

1
1.04
0.27

0.981.11
0.051.46

0.47
0.001

13/14 (92.9)
9/11 (81.8)
28/30 (93.3)
27/28 (96.4)
40/42 (95.2)
91/99 (91.9)

1.01
0.89
1.02
1.05
1.04
1

0.861.18
0.671.10
0.911.14
0.961.15
0.951.13

1
0.26
1
0.68
0.72

Note: NPBCT: new pulmonary bacteriologically confirmed tuberculosis; TB: tuberculosis.

sputum specimens as soon as these are collected to the LRM

through public transportation with transportation charges
immediately refunded at receipt in the LRM. This strategy
seems to be working well and contributes to an increase in
the proportion of retreatment TB patients being tested. For
example, an assessment of the 2014 programme activities of
diagnosis and treatment of TB by the International Union
against Tuberculosis and Lung Diseases estimated that 85% to
92% of retreatment TB patients in that year submitted sputum
specimens to the LRM (Unpublished data, V. Schwoebel,
Benin; TB control Programme, Annual report number 30;
International Union against Tuberculosis and Lung Diseases). Finally, the forthcoming decentralization of Xpert
MTB/RIF machines in regional laboratories will undoubtedly
increase the proportion of patients having sputum specimens
tested and this should accelerate the achievement of 100%
DST.
There are a few other points to note. The proportion
of patients requiring a MDR-TB treatment regimen in the
country in 2013 was not higher in comparison with previous
years [16, 17]. A predominance of males among retreatment
TB cases was found in this study and this has also been
reported elsewhere, although the reasons for this are not
known [18]. Atlantique-Littoral, which houses Cotonou,
the economic capital and the city with the highest density of
population, always reports the highest number of TB cases
in the country; and we are not surprised that this is also the

case for retreatment TB cases. In terms of treatment outcomes

and in comparison with previous reports, there have been
improvements. We noticed that patients who were recorded
as lost to follow-up are no longer at higher risk of defaulting
during their retreatment [6, 7]. The treatment success is also
higher than that observed elsewhere [13]. Furthermore, of the
different types of retreatment TB patients, the highest success
rate was reported in those who relapsed. Possible reasons
for better outcomes include the following: (a) this is a new
exogenous infection with drug-susceptible Mycobacterium
tuberculosis rather than reactivation of a drug-resistant strain
and (b) there is more awareness about TB symptoms and
treatment management from the first experience with the
disease resulting in earlier diagnosis. A worse treatment
outcome was also reported in patients with unknown HIV
status. In this group, it is possible that an HIV-positive
status was known but the patient attempted to hide it with
a consequent lack of appropriate HIV-care delivery.
The study has some implications for the programme.
First, since the large majority of loss to follow-up patients
retreated were from a specific region, there is a need to
address the reasons why these patients stopped their first line
treatment. Second, although the treatment success was good,
we need to be stricter on ensuring that the last follow-up
sputum examination is performed as these patients are being
treated for the second time and are potentially at high risk of
drug resistance. Third, although the proportion of TB patients

Tuberculosis Research and Treatment

with known HIV status is high (96%) in the country [5], it is
important to try to screen all TB cases because of the poor
treatment outcomes in those with unknown HIV status.

5. Conclusion
In 2013, the proportion of retreatment TB patients tested for
culture and DST in Benin was 71%. Although the treatment
success of these patients was encouraging, there is room for
improvement. There is a need to increase the proportion of
patients having the last follow-up sputum examination and
to understand why one of the regions of the country has a
sizeable number of patients recorded as lost to follow-up.

Ethical Approval
The study was approved by the Benin NTP Coordination
and the Ethics Advisory Group of the International Union
against Tuberculosis and Lung Disease, Paris. Because of
its retrospective nature, approval from the national ethics
committee Comite National dEthique pour la Recherche en
Sante was not required according to the countrys recommendations.

Competing Interests
All authors declared no competing interests.

Acknowledgments
The authors thank all workers in the 57 health facilities
involved in tuberculosis management in the country for
their daily hard work. The authors also thank The Union for
technical and financial support in this study. S. Ade is partly
supported as a Union Operational Research Fellow.

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