Drug-resistant TB care met WHO's success target in war-torn South Kivu, Congo

In one of the world's most unstable regions, a routine tuberculosis programme treating drug-resistant cases reached a 77.6% treatment-success rate — clearing WHO's benchmark of at least 75% — even as war and back-to-back outbreaks battered the surrounding health system [s1]. The same cohort study, from South Kivu Province in the eastern Democratic Republic of the Congo, also records the cost of that setting: 13.4% of patients died and 8.6% were lost to follow-up [s1].

Drug-resistant TB (DR-TB) is among the hardest conditions to treat well anywhere, and eastern Congo is close to a worst case for trying. South Kivu has faced protracted insecurity alongside recent COVID-19 and mpox outbreaks, and it borders the provinces at the centre of the country's ongoing Ebola emergency [s1]. Against that backdrop, the study's authors set out to measure how a programmatic DR-TB service — the standard of care a national programme can actually deliver, rather than a trial — performed under sustained strain [s1].

What the cohort showed

The researchers assembled a retrospective provincial cohort of every patient entered in South Kivu's electronic TB registry with drug-resistant disease from January 2018 to June 2024 — 277 people, with a median age of 37 and a range from 3 to 75 years [s1]. HIV status was negative in 79.1% and positive in 9.4% [s1]. Every patient was treated on a bedaquiline-containing regimen, reflecting the shift to all-oral therapy that has replaced older injectable drugs [s1].

Overall treatment success was 77.6%, mortality 13.4% and loss to follow-up 8.6% [s1]. That success rate is notable because WHO's tuberculosis guidance treats a rate of at least 75% as the target for DR-TB programmes, and only about two in five people with drug-resistant TB worldwide even accessed treatment in 2024 [s2]. Reaching the target on all-oral regimens matters for the wider rollout: WHO prioritised a short, six-month all-oral regimen known as BPaLM/BPaL as the treatment of choice for eligible patients in 2022, and roughly 34,000 people with multidrug- or rifampicin-resistant TB started it globally in 2024 [s2].

Two predictors stood out in the adjusted analysis, and they cut against intuition. Living in a rural area was protective against an unsuccessful outcome (adjusted odds ratio 0.42; 95% CI 0.21–0.82; P = .011), a finding that held in time-to-event models (adjusted hazard ratio 0.50; 95% CI 0.29–0.85) [s1]. A history of retreatment other than relapse was associated with worse outcomes (adjusted odds ratio 2.04; 95% CI 1.09–3.81; adjusted hazard ratio 1.71; 95% CI 1.03–2.83) [s1]. The authors note that the deaths and losses to follow-up were concentrated among urban residents [s1].

How much to read into it

A single-province, retrospective cohort of 277 patients cannot settle why urban patients fared worse, and the study is programmatic data rather than a controlled comparison — so factors it did not capture, from disease severity to displacement and treatment interruptions, could lie behind the rural-urban gap [s1]. What the numbers do show is narrower and still useful: that all-oral, bedaquiline-based DR-TB care can clear WHO's success threshold in a conflict-affected setting, which is not a given [s1].

The persistent 13.4% mortality is the counterweight to the headline. It is a reminder that "success above target" and "acceptable outcomes" are not the same thing when one in seven patients dies, and that the gains from better drug regimens can be eroded by the very instability that makes places like South Kivu high-burden in the first place [s1]. For a global TB effort in which most drug-resistant patients still never start treatment at all, the more immediate lesson may be that where such patients are reached, modern regimens hold up even under fire [s2].

This article is informational and is not medical advice.