A winding road leading up a lush green mountain in Swaziland, with a radiant sun shining down, symbolizing hope and progress in the fight against tuberculosis.

Bedaquiline Breakthrough: How Swaziland is Leading the Charge Against Drug-Resistant TB

Rhea Morgan in Health & Wellness December 2025 • 4 min read.

"Discover how Swaziland's innovative approach to implementing bedaquiline is revolutionizing MDR-TB treatment and offering a beacon of hope for countries worldwide."

Multidrug-resistant tuberculosis (MDR-TB) poses a significant global health threat, demanding innovative treatment strategies. Bedaquiline (BDQ), a novel anti-tuberculosis drug, has offered renewed hope, but its implementation in high-burden, low-income countries requires careful planning and execution.

Swaziland, a nation grappling with one of the world's highest MDR-TB burdens, made a bold decision in 2015 to integrate BDQ into its national TB program. This move was driven by the urgent need to improve treatment outcomes, combat the growing resistance to second-line drugs, and address the challenges posed by high rates of HIV co-infection among TB patients.

This article delves into Swaziland's experience with BDQ implementation, showcasing the strategies employed, the challenges encountered, and the remarkable progress achieved. By examining Swaziland's systematic approach, other countries facing similar challenges can gain valuable insights and adapt successful models to their own contexts.

Swaziland's Strategic BDQ Rollout: A Step-by-Step Approach

A winding road leading up a lush green mountain in Swaziland, with a radiant sun shining down, symbolizing hope and progress in the fight against tuberculosis.

Swaziland's success in implementing BDQ hinges on a well-defined, multi-faceted strategy. This approach ensures that the right patients receive the drug, are closely monitored, and benefit from comprehensive support throughout their treatment journey. Key elements of this strategy include:

Patient Eligibility and Selection: BDQ is offered to individuals with MDR-TB who meet specific criteria, including resistance or intolerance to fluoroquinolones or injectable agents. HIV-infected patients and adolescents over 14 are also eligible. A crucial factor is identifying patients with specific genetic mutations (inhA and katG) that predict poorer outcomes with standard treatments. This targeted approach ensures that BDQ is used where it can have the greatest impact.

National Implementation Plan: Swaziland developed a detailed plan in 2015, scaling up BDQ use to four sites by 2016 after readiness assessments. This included ensuring availability of monitoring tools and training for healthcare providers.
Referral Pathways: A streamlined referral system ensures all patients have access to new drugs. RMP-resistant TB cases are sent for line-probe assays, with results sent to regional MDR-TB clinics for monitoring.
Clinical Review Committee: National and international experts review clinical summaries and provide input. The turnaround time for case review is three days.

Treatment Initiation and Monitoring: Swaziland emphasizes comprehensive patient evaluation and support. Before starting BDQ, patients undergo thorough assessments of liver and kidney function, potassium levels, and ECGs to evaluate heart health. Patients receive extensive counseling and sign informed consent forms, often beginning treatment as outpatients.

A Model for Global Impact

Swaziland's pioneering efforts in BDQ implementation offer a beacon of hope for countries grappling with the challenges of MDR-TB. Their systematic approach, characterized by careful patient selection, comprehensive monitoring, and strong partnerships, demonstrates that widespread BDQ use is achievable even in resource-limited settings.

The success in Swaziland underscores the importance of adapting global guidelines to local contexts, building strong healthcare systems, and fostering collaboration among stakeholders. By sharing their experiences and lessons learned, Swaziland is empowering other nations to implement BDQ effectively and improve outcomes for patients with MDR-TB.

As the global community strives to combat the TB epidemic, Swaziland's model serves as a powerful reminder that strategic implementation and unwavering commitment can pave the way for a future free from the burden of drug-resistant tuberculosis.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.5588/pha.17.0054, Alternate LINK

Title: Operational Aspects Of Bedaquiline Implementation In Swaziland: Report From The Field

Subject: Public Health, Environmental and Occupational Health

Journal: Public Health Action

Publisher: International Union Against Tuberculosis and Lung Disease

Authors: D. Vambe, T. Dlamini, J. Furin, C. Gracia-Edwards, K. Keus, K. Kunene, A. Shabangu, S. N. Dlamini, W. Sikhondze

Published: 2017-09-21

Everything You Need To Know

Why did Swaziland decide to integrate bedaquiline into its national TB program?

Swaziland strategically integrated bedaquiline into its national TB program in 2015 due to the urgent need to improve treatment outcomes for multidrug-resistant tuberculosis, combat resistance to second-line drugs, and address challenges posed by high rates of HIV co-infection among TB patients. Their systematic approach includes patient eligibility and selection, a detailed national implementation plan, streamlined referral pathways, and a clinical review committee.

Who is eligible to receive bedaquiline treatment in Swaziland?

In Swaziland, bedaquiline is offered to individuals diagnosed with MDR-TB who exhibit resistance or intolerance to fluoroquinolones or injectable agents. The eligibility extends to HIV-infected patients and adolescents over 14. Identification of patients with specific genetic mutations, such as inhA and katG, which predict poorer outcomes with standard treatments, is a crucial factor in the selection process.

What kind of patient evaluations are performed before starting bedaquiline treatment in Swaziland?

Prior to initiating bedaquiline treatment in Swaziland, patients undergo thorough evaluations of their liver and kidney function, potassium levels, and ECGs to assess heart health. This comprehensive assessment ensures patient safety and helps in managing potential side effects. Patients also receive extensive counseling and sign informed consent forms, often starting treatment as outpatients, emphasizing patient involvement and understanding.

What were the key components of Swaziland's plan to scale up bedaquiline use?

Swaziland established a detailed National Implementation Plan in 2015 to scale up bedaquiline use, starting with readiness assessments at four sites by 2016. This plan ensured the availability of necessary monitoring tools and provided training for healthcare providers. Additionally, a streamlined referral system was established to facilitate access to new drugs for all patients, with RMP-resistant TB cases undergoing line-probe assays, and results being sent to regional MDR-TB clinics for monitoring.

What are the key elements that made Swaziland's implementation of bedaquiline successful, and how can it be a model for other countries?

Swaziland's systematic implementation of bedaquiline involves careful patient selection based on resistance profiles and genetic mutations (inhA and katG), comprehensive patient monitoring to ensure safety and efficacy, and strong collaborative partnerships between national and international experts through a clinical review committee. This approach serves as a model for widespread bedaquiline use, even in resource-limited settings, demonstrating that strategic planning and execution can lead to significant improvements in MDR-TB treatment outcomes globally.