Drug-resistant tuberculosis treatment

Psychological support. Psychological support was varied and could include self-help groups, alcohol 
cessation counselling and TB clubs examined in both RCTs and observational studies (165, 183, 229). 
Based on an assessment of the certainty of the evidence, carried out using predefined criteria and 
documented in GRADEpro, the certainty of the evidence was rated as very low to high, depending 
on the outcome being assessed and type of study. Patients who had access to psychological support 
had higher rates of treatment completion and cure, as well as lower rates of treatment failure and loss 
to follow-up. However, the GDG had concerns about confounding in these studies due to the severity 
of illness in the groups receiving support. Additionally, allocation of patients to the support groups 
was not always randomized. When considering these data, it should also be noted that psychological 
support types are very broad and may not be adequately represented in this review. To maximize 
health equity, psychological support should be targeted at the most marginalized
populations.
Ambulatory care. Outcomes from models of MDR-TB care based mainly on clinic-based ambulatory 
treatment were compared with those using mainly hospital-based inpatient treatment. The data used 
came from cost–effectiveness studies in four countries (Estonia and the Russian Federation [Tomsk 
oblast] (230), Peru (231) and the Philippines (232)).The design of these observational studies did not 
allow direct comparison of effects between models of care. Given that none of the studies were RCTs, 
the evidence was considered of very low quality. Cost–effectiveness was modelled for all possible 
WHO Member States in a probabilistic analysis of the data from the four countries (233).
A high value was placed on conserving resources and on patient outcomes such as preventing death 
and transmission of MDR-TB as a result of delayed diagnosis and inpatient treatment. There should 
always be provision for a back-up facility to manage patients who need inpatient treatment. This may 
be necessary in certain patient groups at particular risk, such as children during the intensive phase, 
among whom close monitoring may be required for a certain period of
time.