SMART4TB and the BETTER Project co-hosted a two-day meeting in Johannesburg last week to address the growing issue of expanded resistance to TB drugs. Bedaquiline, clofazimine, delamanid, linezolid, and pretomanid are the backbones of shorter, safer, more effective regimens for rifampin-resistant TB. However, resistance to them poses enormous challenges for affected individuals and the clinicians and programs who treat them.

Leading front-line clinicians, affected community members, and representatives from national TB programs convened to share experiences and develop best practices for this rising concern. They discussed the complicated decision-making process involved in treating and receiving treatment for a type of TB with limited options. This involved weighing the side effects and risks against the goals for the person living with TB, the physician, and the national TB program. They concluded that structured approaches to care for people living with expanded resistance to TB drugs should include:

• Timely access to genomic sequencing to identify drug-resistance mutations to enable early detection of expanded resistance to guide treatment;
• Wraparound care with holistic counseling and shared decision-making between the healthcare provider and person living with expanded drug resistance;
• Urgent development of equitable programs, developed in consultation with key affected communities, for pre-approval access to new drugs. These programs should include both clinical trials and compassionate use. The BETTER Project stands ready to provide clinical support to these programs and calls on drug developers and donors to prioritize this work; and
• Data collection using common elements and existing shared platforms to capture the extent of expanded resistance and outcomes to inform evidence-based policymaking.

SMART4TB and BETTER will produce a clinical field guide in the coming months, further detailing the above practices. If you are interested in receiving the field guide and learning more about our joint efforts, sign up for SMART4TB updates or follow us on LinkedIn. We will also distribute the field guide on our website and through TB listservs. If you are a provider treating expanded DR-TB, please contact Jen Furin at jenniferfurin@gmail.com and if you are a survivor and want to share your story, please contact Rekha Radhakrishnan at rradhak5@jh.edu.