MDR tuberculosis and non-compliance with therapy.

178 www.thelancet.com/infection Vol 12 March 2012 3 World Health Organization. Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drugresistant tuberculosis by 2015: WHO progress report 2011. http://whqlibdoc.who.int/ publications/2011/9789241501330_eng.pdf (accessed Mar 24, 2011). 4 Upshur R, Singh J, Ford N. Apocalypse or redemption: responding to extensively drug-resistant tuberculosis. Bull World Health Organ 2009; 87: 481–83. 5 London L. Confi nement for extensively drug-resistant tuberculosis: balancing protection of health systems, individual rights and the public’s health. Int J Tuberc Lung Dis 2009; 13: 1200–09. required, that might reduce the risk of transmission to others, as is being attempted in South Africa. As case detection and treatment for MDR tuberculosis is scaled up internationally, how to care for patients who have exhausted all treatment options with existing second-line drugs will become increasingly important. Currently, no third-line treatment for tuberculosis exists. Until newer drugs become available, we will need to care for such patients in a manner that balances the risk of ongoing transmission with individual human rights. The health system must still support patients in whom treatment has failed. The provision of homebased palliative care, for example, is likely to be more humane and less costly to health services compared with involuntary detention. Although a small proportion of patients might realistically be classifi ed as recalcitrant, and legal means may be necessary to restrict transmission, we feel that every eff ort should be made to support patients, either to continue treatment if they so wish, or to live out the remainder of their lives in a manner that minimises the risk of transmission to others. In this case, the threat of incarceration is also likely to further reduce the chances that this patient will be located. We feel that such patients should not be managed by an automatic resort to legal coercion.