ART uptake,its timing and relation to anti-tuberculosis treatment outcomes among HIV-infected TB patients

Setting:

All public health facilities in two provinces of Zimbabwe.

Objective:

To determine, among tuberculosis (TB) patients with human immunodeficiency virus (HIV) registered in 2010, 1) the proportion started on antiretroviral treatment (ART), 2) the timing of ART in relation to the start of anti-tuberculosis treatment, and 3) whether timing of ART influenced anti-tuberculosis treatment outcomes.

Design:

Retrospective cohort study.

Results:

Of the 2655 HIV-positive TB patients, 1115 (42%) were documented as receiving ART. Of these, 178 (16%) started ART prior to anti-tuberculosis treatment. Of those who started after anti-tuberculosis treatment, 17% started within 2 weeks, 43% between 2 and 8 weeks and 40% after 8 weeks. Treatment success in the cohort was 82%, with 14% deaths before completion of anti-tuberculosis treatment. Not receiving ART during anti-tuberculosis treatment was associated with lower anti-tuberculosis treatment success (adjusted RR 0.70, 95%CI 0.53–0.91) and more deaths (adjusted RR 3.43, 95%CI 2.2–5.36). There were no differences in TB treatment outcomes by timing of ART initiation.

Conclusion:

ART uptake is low given the improved treatment outcomes in those put on ART during anti-tuberculosis treatment. Better integration of HIV and TB services is needed to ensure increased coverage and earlier ART uptake.     

Decline in adverse outcomes and death in tuberculosis patients in Malawi: association with HIV interventions

Between 2000 and 2012, the annual numbers of patients treated for tuberculosis (TB) in Malawi declined by 28%, from 28 234 to 20 463. During this time, the proportion of TB patients tested for the human immunodeficiency virus (HIV) increased from 6% to 87%. Most HIV-infected patients received cotrimoxazole preventive therapy, and the proportion receiving antiretroviral therapy increased to 88%. Between 2000 and 2008 there was a significant decline in all adverse outcomes (from 31% to 14%), and particularly in deaths (from 23% to 10%) and loss to follow-up (from 5.2% to 1.9%, P < 0.001). After 2008, there was no decrease in any adverse outcome. Ways to further reduce TB-associated mortality are discussed.     

The burden and treatment outcomes of extra-pulmonary tuberculosis in Bhutan

Setting:

All tuberculosis (TB) registration sites in Bhutan.

Design:

Cross-sectional study involving a retrospective review of TB registers and TB treatment cards.

Objectives:

To determine: 1) the number and proportion of all TB cases registered as extra-pulmonary TB (EPTB) from 2001 to 2010, 2) the age and sex of the patients and the categories and types of EPTB registered in 2010, and 3) their treatment outcomes.

Results:

The proportion of all TB cases registered as EPTB over a period of 10 years varied from 30% to 40%. In 2010, 505 patients were registered with EPTB, of whom 50% were male, 21% were children, and 96% were new EPTB cases. TB lymph node enlargement and pleural effusion were the two most common types of EPTB, accounting for 67%, followed by abdominal TB and spinal/bone/kidney disease. The overall treatment success rate was 90%, and was generally similar with respect to sex, age and different types of EPTB.

Conclusion:

Bhutan has a high proportion of patients registered as having EPTB, for whom treatment outcomes are satisfactory. Further work is needed to better understand how EPTB is diagnosed throughout the country.     

Using focus groups to develop HIV education among adolescent females in Zimbabwe

Seventy-eight adolescent females from Zimbabwe participatedin focus groups to assess need for HIV/AIDS prevention and education.The interview guide dealt with HIV transmission, preventionand education. Results show a high level of awareness regardingHIV transmission, however, myths and misconceptions still persist.General AIDS information was perceived as widely available,but individual counseling was perceived as nonexistent. Althoughmost of the young women still hold to traditional values regardingmarriage, negative male sexual attitudes and economic hardshipswere perceived as major factors that make females of their agevulnerable to HIV infections. Participants recommended face-to-face,gender-specific HIV/AIDS prevention and education. Nurses, physicians,persons living with AIDS and church officials were identifiedas possible facilitators. Based on this focus group experience,future efforts in developing comprehensive AIDS prevention andeducation programs should target adolescent and adult malesin order to assess salient issues regarding HIV/AIDS preventionand education.     

Measuring the quality of hospital tuberculosis services: a prospective study in four Zimbabwe hospitals.

OBJECTIVE: To show how the use of a prospective approach to measuring the quality of services for a specific diagnosis can generate useful information for improving the quality of services in environments with limited information technology and data. DESIGN: Tracer approach focusing on intensive treatment of tuberculosis in hospital. The study was conducted in Zimbabwe in 1999. Local tuberculosis management guidelines were first translated into explicit quality assessment criteria and a panel of public health experts assisted in weighting different factors (structural and process) of the criteria. Factor weightings were based on both local knowledge and experience, and potential contribution of a factor to the likelihood of a positive outcome. A total of 138 patients was recruited into the study cohort at admission and followed up to discharge. An assessment of what was done to and for the patient was made for the entire hospitalization episode using explicit criteria. Comparisons were made between actual and maximum performance scores. SETTING: The study was conducted at four regional referral hospitals. The hospitals serve at least six secondary hospitals, and several public and private primary care facilities. The hospitals have a dual role as they also provide secondary care to their immediate catchment population. RESULTS: Notable quality gaps are observed between actual and maximum quality levels in all four hospitals although the size of the gap differed significantly. Variation in the quality of services between the hospitals is explained by distinguishable differences in structural and process aspects of tuberculosis management. CONCLUSIONS: It is feasible to conduct prospective quality assessment in developing countries with minimal disruption of routine activities. The study also showed that prospective exploration of health care quality for a specific diagnosis can provide insights into hospital-level quality issues. Such information is useful for monitoring and improving the quality of hospital services in general.     

Structural barriers and human rights related to HIV prevention and treatment in Zimbabwe

Abstract

There has long been recognition that individual risk factors can only partially explain vulnerability to HIV infection, and that a broader range of socioeconomic, cultural and political factors must be taken into account. More recently this understanding has been applied to addressing obstacles to accessing HIV treatment. Yet, while structural interventions aimed at contextual factors related to HIV prevention and treatment have been shown to be effective, they have not been widely implemented. Using the situation of Zimbabwe as an example, we will present an illustration of how contextual barriers can be understood in human rights terms, and how using a human rights analysis can specifically help define ‘structural-rights’ interventions and compel their implementation.     

The temporalities of policymaking: The case of HIV test-and-treat policy adoption in Zimbabwe

Despite calls for “rapid adoption” of global health policies and treatment guidelines; there is little understanding of the factors that help accelerate their adoption and implementation. Drawing on in-depth interviews with sixteen Zimbabwean policymakers, we unpack how different factors, rhythmic experiences and epochal practices come together to shape the speeding up and slowing down of test-and-treat implementation in Zimbabwe. We present an empirically derived framework for the temporal analysis of policy adoption and argue that such analysis can help highlight the multiple and messy realities of policy adoption and implementation - supporting future calls for ‘rapid’ policy adoption.     

Contrasting causal pathways contribute to poorer health and nutrition outcomes in orphans in Zimbabwe

Orphaned children have been found to be at greater risk of poor health and malnutrition compared to non-orphans in sub-Saharan African countries. However, levels of disadvantage vary by location and little is known about the causal pathways that lead from orphanhood to poorer health and malnutrition. Aggregate data from recent Demographic and Health Surveys in 22 countries were used to compare overall levels of ill-health and malnutrition by orphan status. Data from the Manicaland Child Cohort Study in Zimbabwe – a closed cohort study with detailed longitudinal information on orphan's experience – were used to describe how patterns of ill-health and malnutrition alter over the child's life-course and to test causal pathways between orphanhood and ill-health and malnutrition, hypothesized in a previously published theoretical framework. Modest increases in ill-health and malnutrition were found in orphans in the Demographic and Health Surveys data, with maternal and double orphans being worst affected. Non-significant associations were found between orphanhood and ill-health in the Manicaland Child Cohort Study data, but no associations with malnutrition were found. None the less, smaller increases in body mass index with age were seen among orphans (ologit test for difference: adjusted odds ratio?=?0.68; p?=?0.07) and maternal orphans (ologit test for difference: adjusted odds ratio?=?0.67; p?=?0.03) than among non-orphans. Stigma and discrimination contributed to poor diet, malnutrition and ill-health in children whose mothers had died, while heightened poverty was a more important factor for paternal orphans. These results suggest social and psychological support for orphans and their families could be as important as material support in preventing malnutrition and ill-health.     

Culture,myths and panic: Three decades and beyond with an HIV/AIDS epidemic in Zimbabwe

Zimbabwe is going through a generalised acquired immunodeficiency syndrome (AIDS) epidemic. The first five years of the epidemic (1985-1990) were characterised by lack of medicines against human immunodeficiency virus (HIV), and an exponential increase in prevalence (65-fold) and incidence (13-fold), which were fuelled by high-risk sexual behaviour. The high HIV prevalence, mortality and stigma yielded great fear and panic in the population, which are thought to have led to confusion and hopelessness, and, in turn, increased risky sexual behaviour. The country’s government and civil society embarked on HIV awareness campaigns that are claimed to have played a central role in slowing down the epidemic since the mid-2000s. HIV-related mortality then fell by 70% between 2003 and 2013, which is attributed to high uptake of antiretroviral therapy (ART) and prevention of mother-to-child transmission (95%) prophylaxis. However, the epidemic has been characterised by a low paediatric ART coverage (35% in 2011 to 46.12% in 2013). Year 2014 saw an increase in adolescent and young adult HIV prevalence, which may be signalling a rebound of the epidemic. A more holistic approach which deals with the epidemic in its socio-political context is required to effectively lower the country’s HIV burden.     

Education,substance use,and HIV risk among orphaned adolescents in Eastern Zimbabwe

There is a growing interest in education as a means to reduce HIV infection in vulnerable children in sub-Saharan Africa; however, the mechanisms by which education reduces HIV infection remain uncertain. Substance use has been associated with high-risk sexual behaviour and could lie on the causal pathway between education and HIV risk. Therefore, we used multivariable regression to measure associations between: (i) orphanhood and substance use (alcohol, recreational drugs, and smoking), (ii) substance use and sexual risk behaviours, and (iii) school enrolment and substance use, in adolescents aged 15–19 years, in Eastern Zimbabwe. We found substance use to be low overall (6.4%, 3.2%, and 0.9% of males reported alcohol, drug, and cigarette use; <1% of females reported any substance use), but was more common in male maternal and double orphans than non-orphans. Substance use was positively associated with early sexual debut, number of sexual partners, and engaging in transactional sex, while school enrolment was associated with lower substance use in males. We conclude that education may reduce sexual risk behaviours and HIV infection rates among male adolescents in sub-Saharan Africa, in part, by reducing substance abuse.     

Factors affecting treatment outcomes in drug-resistant tuberculosis cases in the Northern Cape,South Africa

The Northern Cape Province has low cure rates (21%) for multidrug-resistant tuberculosis (TB). We audited the programme to identify factors affecting treatment outcomes. Cases admitted to two drug-resistant TB units from 2007 to 2009 had data extracted from clinical folders. Unfavourable treatment outcomes were found in 58% of the 272 cases. A multivariable regression analysis found that male sex was associated with unfavourable outcome (P = 0.009). Weight at diagnosis (P < 0.001) and oral drug adherence (P < 0.001) were also associated with an unfavourable outcome; however, injectable drug adherence was not (P = 0.395). Positive baseline smear and human immunodeficiency virus positive status were not associated with unfavourable outcome. Shorter, more patient-friendly regimens may go a long way to improving adherence and outcomes.     

安徽省某市结核病人中HIV感染状况分析

目的了解安徽省某市结核病人中HIV感染情况,为制定结核病和艾滋病双重感染防治对策提供科学依据。方法对新登记人项的1212例结核病人用酶联免疫法进行HIV初筛试验,初筛阳性者进行免疫印迹法确认试验进行确认,并进行流行病学调查。结果1212例结核病人检出HIV感染者4例（其中死亡1例）,感染率为0．33％,其中健在的3例中,2例男性,1例女性;民工2例,农民1例,平均年龄为（34．00±10．44）岁,传播途径均为性传播。结论结核病人中HIV感染率高于一般人群,应在结核病人群中加强艾滋病的宣传教育和行为干预。     

Tuberculosis transmission attributable to close contacts and HIV status, Malawi

We conducted the first molecular study of tuberculosis (TB) to estimate the role of household contact and transmission from HIV-positive putative source contacts (PSCs) in a high HIV-prevalence area. TB patients in a long-term population-based study in Malawi were asked about past contact with TB. DNA fingerprinting was used to define clusters of cases with identical strains. Among 143 epidemiologically defined PSC-case pairs, fingerprinting confirmed transmission for 44% of household and family contacts and 18% of other contacts. Transmission was less likely to be confirmed if the PSC were HIV positive than if he or she was HIV negative (odds ratio 0.32, 95% confidence interval [CI] 0.14-0.74). Overall, epidemiologic links were found for 11% of 754 fingerprint-clustered cases. We estimate that 9%-13% of TB cases were attributable to recent transmission from identifiable close contacts and that nearly half of the TB cases arising from recent infection had acquired the infection from HIV-positive patients.     

Infection control in households of drug-resistant tuberculosis patients co-infected with HIV in Mumbai,India

Background: Mumbai has a population of 21 million, and an increasingly recognised epidemic of drug-resistant tuberculosis (DR-TB).Objective: To describe TB infection control (IC) measures implemented in households of DR-TB patients co-infected with the human immunodeficiency virus (HIV) under a Médecins Sans Frontières programme.Methods: IC assessments were carried out in patient households between May 2012 and March 2013. A simplified, standardised assessment tool was utilised to assess the risk of TB transmission and guide interventions. Administrative, environmental and personal protective measures were tailored to patient needs.Results: IC assessments were carried out in 29 houses. Measures included health education, segregating sleeping areas of patients, improving natural ventilation by opening windows, removing curtains and obstacles to air flow, installing fans and air extractors and providing surgical masks to patients for limited periods. Environmental interventions were carried out in 22 houses.Conclusions: TB IC could be a beneficial component of a comprehensive TB and HIV care programme in households and communities. Although particularly challenging in slum settings, IC measures that are feasible, affordable and acceptable can be implemented in such settings using simplified and standardised tools. Appropriate IC interventions at household level may prevent new cases of DR-TB, especially in households of patients with a lower chance of cure.     

A hospital-based tuberculosis focal point to improve tuberculosis care provision in a very high burden setting

Setting:

A hospital-based tuberculosis focal point (TBFP) at a tertiary hospital in Johannesburg, South Africa.

Objective:

To describe the possible tasks and impact of a hospital-based TBFP as well as staffing and infrastructure requirements for setting up a hospital-based TBFP.

Activities:

A TBFP can centralize the notification and referral of new TB cases, perform human immunodeficiency virus counseling and testing, assessment of difficult to diagnose TB suspects and management of complicated TB cases, and it can provide an ideal setting for research and health care worker training.

Results:

The number of TB suspects assessed by sputum initially increased, followed by a decrease starting in 2010, which correlates with the globally decreasing TB incidence. The proportion of TB cases who failed to link to TB care decreased from 23% to 14% between 2009 and 2012. Almost 40% of cases with hepatotoxicity required an adjusted treatment regimen. Roll-out of Xpert^® MTB/RIF testing and decentralized drug-resistant TB treatment increased the number of rifampicin monoresistant and sputum smear-negative multidrug-resistant TB cases treated on an out-patient basis.

Conclusion:

A hospital-based TBFP complements care at primary care level by coordinating TB care for a vulnerable population of patients diagnosed in a hospital setting, and by coordinating the diagnosis and treatment of complex TB cases.     

武汉市HIV/AIDS患者潜伏性结核感染筛查及预防效果

目的　探讨武汉市HIV/AIDS患者潜伏性结核感染（latent tuberculosis infection, LTBI）筛查的可行性,明确预防治疗存在的问题,为制定适合该人群LTBI筛查及预防流程提供依据。方法　选取2016年1月—2018年12月在武汉市13所HIV/AIDS定点治疗单位随访的2048例HIV/AIDS患者作为研究对象,根据2015版LTBI管理指南筛查流程,筛查LTBI患者并进行6个月异烟肼预防治疗（isoniazid preventive therapy, IPT）。结果　2048例HIV/AIDS患者中,结核病症状调查发现5.2%（107/2048）的患者出现结核病症状,94.8%（1941/2048）的无结核病症状患者进行γ-干扰素释放试验（interferon-gamma release assay, IGRA）,IGRA阳性率为21.4%（415/1941）。IGRA阳性者胸片筛查发现,98.1%（407/415）的患者胸片无结核感染表现,诊断为LTBI,约占筛查总人数的19.9%（407/2048）。86.2%（351/407）的LTBI患者接受IPT,其中90.0%（316/351）的患者完成了6个月IPT,随访至12个月后,发现IPT组有1.7%（6/351）进展为活动性结核病（active tuberculosis, ATB）,非IPT组有8.9%（5/56）进展为ATB,2组比较差异有统计学意义（χ2=8.170,P=0.004）。结论　在武汉市HIV/AIDS患者中,LTBI发生率约为19.9%,IPT可以降低HIV/AIDS患者LTBI进展为ATB的风险,且不良反应少,但接受IPT比例和治疗完成率偏低,须建立督导机制,以提高IPT的接受率和完成率。     

2015-2017年度韶关市结核病就诊患者耐多药情况分析

目的  探析位于粤北山区的韶关市2015-2017年度耐多药肺结核患者（multi drug resistant pulmonary tuberculosis,MDR-TB）的筛查情况。 方法  回顾性分析562例可疑MDR-TB患者及新患者的临床资料,所有患者均接受了传统药敏试验,统计异烟肼（isonicotinyl hydrazide,INH）、利福平（rifampicin,RFP）、乙胺丁醇（Ethambutol,EMB）、链霉素（streptomycin,SM）、氧氟沙星（ofloxacin,Ofx）、卡那霉素（kanamycin,Km）耐药情况及MDR-TB筛查结果。 结果  传统药敏试验结果中,SM的耐药率最高,达19.22%（108/562）,KM的耐药率最低,为4.45%（25/562）。562例患者的传统确诊结果显示,MDR-TB检出率为6.94%（39/562）。MDR-TB检出率在性别、年龄、文化程度、地区之间均无统计学意义（均有P>0.05）;不同患者类型的MDR-TB检出率之间有统计学意义（P < 0.001）。 结论  肺结核患者耐药率顺位依次为链霉素、异烟肼、利福平、乙胺丁醇、氧氟沙星和卡那霉素。复治组患者的单耐药率、耐多药率均高于初治组。应以复治患者为重点,扩大筛查范围,及时治愈初治患者。     

Screening of new entrants for tuberculosis: responses to port notifications

BACKGROUND: Tuberculosis in England and Wales is associated with recently arrived immigrants. Screening new entrants for tuberculosis has received considerable attention recently. Despite several calls to reorganize screening processes for new entrants because of perceived ineffectiveness, some systems at ports have remained largely unchanged, including notification arrangements. METHODS: A postal questionnaire was sent to Consultants in Communicable Disease Control (CsCDC) who normally receive port health notification forms from London Heathrow Port Health Control Unit relating to new entrants who had either been screened and found to have a normal chest X-ray, not had an chest X-ray due to pregnancy or young age or whose examination was inconclusive (Port 101 and 102 forms). RESULTS: Almost half of the responding CsCDC attempted to follow-up all Port 101 and 102 referrals; of these CsCDC, 46 percent reported that they were actually able to follow-up under 50 percent. CsCDC had developed their own criteria to aid decisions as to which referrals to follow-up. CONCLUSION: The follow-up by CsCDC of new entrants passing through Heathrow Port Health Control Unit who have been screened and found to have a normal chest X-ray, not had an X-ray due to pregnancy or young age, or whose examination was inconclusive varies considerably and there is no consistent national practice. Substantial efforts are being expended on attempting to follow-up new entrants, many of whom may be at low risk of tuberculosis. The effectiveness (and efficiency) of this approach is probably low.