TB drug resistance is a major problem that threatens the success of DOTS, the WHO-recommended treatment strategy for detection and cure of TB, as well as global tuberculosis control. Drug resistance arises due to the improper use of durgs in chemotherapy of drug-susceptible TB patients. This improper use is a result of a number of actions, including administration of improper treatment regimens by health care providers and failure to ensure that patients complete the whole course of treatment. Essentially, drug-resistance arises in areas with poor TB control programmes.The DOTS-Plus programme is developed by WHO and partners to manage Drug Resistant-TB (DR-TB) using second-line Anti-TB drugs. Based upon DOTS, DOTS-Plus is a comprehensive management strategy under development and testing that includes the five tenets of the DOTS strategy.

DOTS-Plus takes into account specific issues (such as the use of second-line anti-TB drugs) that need to be addressed in areas where there is high prevalence of DR-TB. Thus, DOTS-Plus works as a supplement to the standard DOTS strategy. By definition,it is impossible to conduct DOTS-Plus in an area without having an effective DOTS-based TB control programme in place. DR-TB requires longer duration of treatment (up to 2 years) to achieve cure, in comparison with 8 months treatment for drug susceptible TB. DR-TB has much higher level of mortality than drug susceptible TB, lower cure rates and even higher default rates. Infection control of DR-TB are more difficult to implement in hospitals due long time until DST results available, and start adequate treatment as well as more side effects are associated with second line Anti-TB drugs treatment. The cost of drugs to treat a DR-TB case can be up to 100 times more than the cost of treating a drug susceptible TB case. DR-TB situation in Nepal has been well controlled due to quality DOTS expansion. In collaboration with the IUATLD/WHO Global Surveillance programme NTP has been conducting repeated national surveys of drug resistance in newly registered TB cases. The latest survey shows that during the rapid expansion of the Tuberculosis programme the incidence of Multiple Drug resistance in new TB cases has not increased, but remained stable at a low level (1.3%).

Our monitoring data shows that only around 1% of smear positive patients fail initial DOTS treatment and need to be retreated. Some of these patients have DR TB and now being treated within DOTS PLUS PILOT. It is estimated that of the 33,000 patients who get treatment under DOTS every year about 150 will end up needing further treatment for DR TB. The Nepal DOTS PLUS programme for the treatment of DR TB is the first pilot project in South East Asia and approved by the WHO based Green Light Committee (GLC) who are also providing quality assured second line TB drugs at subsidized rates. DOTS Plus programme for treatment of Drug Resistant TB (DR TB) started by Nepal NTP in September 2005. Initial approval is for Nepal NTP to register 350 DR TB cases over a two year period. DOTS Plus programme started at 5 main centers and 16 sub-centers. By end December 2006 over 250 patients were registered at five main treatment center or sub treatment centers and the sputum at six months was over 70%. The first international annual review of the DOTS PLUS programme was done in September 2006 by Green Light Committee (Stop TB Department WHO Geneva).

The conclusion of this review was that the DOTS-Plus programme in Nepal is well organized, delivering a standardized treatment with adequate initial sputum conversion rates, and is fully functioning within the GLC guidelines.