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.     

Timing of antiretroviral therapy and effects on tuberculosis treatment outcomes in HIV-co-infected patients in Malawi

Setting:

Queen Elizabeth Central Hospital, Blantyre, Malawi.

Objectives:

To determine 1) the proportion of human immunodeficiency virus (HIV) infected tuberculosis (TB) patients started on antiretroviral therapy (ART), 2) the timing of ART and 3) the effect of the timing on TB treatment outcomes.

Design:

A retrospective record review of HIV-infected TB patients registered from January to December 2009.

Results:

A total of 3376 TB patients were registered, of whom 2665 (79%) were HIV-tested and 2042 (77%) were HIV-infected. A total of 1190 HIV-infected TB patients who were not on ART at the time of starting TB treatment were studied. Of 688 (58%) who started ART, 61% started therapy within 2 months of anti-tuberculosis treatment and 39% started later (≥2 months). Treatment success for patients with TB who started ART within 2 months was higher than for those starting ART later (RR 1.6, 95%CI 1.4–1.8), and death rates were lower (RR 0.25, 95%CI 0.19–0.35).

Conclusion:

Under routine programme conditions in Malawi, a higher proportion of HIV-infected TB patients who started ART did so within 2 months of starting TB treatment, and early ART intervention was associated with better treatment outcomes. This confirms recommendations that co-infected TB patients should start ART early.     

Antiretroviral therapy uptake among adult tuberculosis patients newly diagnosed with HIV in Nyanza Province,Kenya

Setting:

In 2008, the Kenya tuberculosis (TB) program reported low (31%) antiretroviral therapy (ART) uptake among human immunodeficiency virus (HIV) infected TB patients.

Objective:

To confirm ART coverage and identify factors associated with HIV clinic enrollment and ART initiation among TB patients.

Design:

Retrospective chart abstraction of adult TB patients newly diagnosed with HIV and eligible for ART at 58 Nyanza Province TB clinics between October 2006 and April 2008. TB data were linked to HIV clinic data at 50 facilities that provided ART. Associations with HIV clinic enrollment and ART were evaluated.

Results:

Among 1137 ART-eligible TB patient records sampled, 32% documented HIV clinic enrollment and 29% ART. Date fields were largely incomplete; 11% of the patient records included HIV testing dates and ≤1% had dates for cotrimoxazole prophylaxis, HIV clinic enrollment and ART initiation. Adding HIV clinic data increased HIV clinic enrollment and ART documentation to respectively 62% and 44%. Among TB patients in HIV care, female sex, older age group and baseline CD4 documentation were associated with ART initiation.

Conclusion:

Linking data increased documentation of HIV clinic enrollment and ART uptake. Continued efforts are required to improve the documentation of HIV service delivery, especially in TB clinics. Interventions to increase ART uptake are needed for younger patients and men.     

Timing and uptake of ART during treatment for active tuberculosis in HIV co-infected adults in Malawi

Setting:

Uptake of antiretroviral therapy (ART) in patients co-infected with tuberculosis (TB) and the human immunodeficiency virus (HIV) has historically been low in Malawi. In response, the National TB Programme piloted the initiation of ART 2 weeks after initiation of TB treatment in 2008–2009, a change from the prior policy of 2 months.

Objective:

To determine at programme level if earlier initiation of ART in co-infected patients receiving TB treatment will increase the uptake and continuation of ART.

Design:

A prospective observational pilot programme evaluation using routinely collected monitoring data from the first two sites with integrated TB-HIV services in Malawi.

Results:

There was wide variability in the ART start time before and after the policy change. Before the policy change, 16% of patients initiated ART by 3 months compared to 24% after the policy change (P < 0.001). The proportion of all co-infected patients on ART increased from 32% before the policy change to 39% after (P < 0.001). Earlier initiation of ART did not increase the occurrence of side effects and did not reduce adherence to TB treatment.

Conclusion:

Earlier initiation of ART in co-infected patients receiving TB treatment improved the uptake and continuation of ART. Malawi ART guidelines in 2011 were changed from initiating ART after 2 months to as soon as possible after starting anti-tuberculosis treatment.     

Uptake of HIV testing and HIV positivity among presumptive tuberculosis patients at Puducherry,South India

Setting:

Puducherry, a district in South India with a low prevalence of human immunodeficiency virus (HIV) infection (<1% among antenatal women).

Objectives:

1) To estimate the proportion of patients with known HIV status who were HIV-positive, 2) to describe the demographic and clinical characteristics of patients with unknown HIV status among presumptive TB patients, and 3) to assess the additional workload at HIV testing centres.

Design:

In this cross-sectional study, consecutive presumptive TB patients attending microscopy centres for diagnosis during March–May 2013 were asked if they knew their HIV status. Patients with unknown HIV status were offered voluntary counselling and HIV testing.

Results:

Of 1886 presumptive TB patients, HIV status was ascertained for 842 (44.6%); 28 (3.3%) were HIV-positive. The uptake of HIV testing was significantly higher in younger age groups, males, residents of Puducherry and smear-positive TB patients. The median increase in the number of clients tested for HIV per day per testing centre was 1 (range 0–6).

Conclusion:

The uptake of HIV testing was low. HIV prevalence was higher among presumptive TB patients than in antenatal women, and as high as in TB patients. With minimal increase in workload at HIV testing centres, HIV testing could be implemented using existing resources.     

The burden and outcomes of childhood tuberculosis in Cotonou,Benin

Setting:

The National Tuberculosis Programme (NTP) and the paediatric ward of the General Hospital (GH), Cotonou, Benin.

Objective:

To describe the burden of tuberculosis (TB), characteristics and outcomes among children treated in Cotonou from 2009 to 2011.

Design:

Cross-sectional cohort study consisting of a retrospective record review of all children with TB aged <15 years.

Results:

From 2009 to 2011, 182 children with TB were diagnosed and treated (4.5% of total cases), 153 (84%) by the NTP and 29 (16%) by the GH; the latter were not notified to the NTP. The incidence rate of notified TB cases was between 8 and 13 per 100 000 population, and was higher in children aged >5 years. Of 167 children tested, 29% were HIV-positive. Treatment success was 72% overall, with success rates of 86%, 62% and 74%, respectively, among sputum smear-positive, sputum smear-negative and extra-pulmonary patients. Treatment success rates were lower in children with sputum smear-negative TB (62%) and those with HIV infection (58%).

Conclusion:

The number of children being treated for TB is low, and younger children in particular are underdiagnosed. There is a need to improve the diagnosis of childhood TB, especially among younger children, and to improve treatment outcomes among HIV-TB infected children, with better follow-up and monitoring.     

Diagnostic management and outcomes of pulmonary tuberculosis suspects admitted to a central hospital in Malawi

Setting:

Zomba Central Hospital, Malawi.

Objective:

To determine diagnostic management and outcomes of pulmonary tuberculosis (PTB) suspects admitted to adult wards.

Design:

A retrospective, cross-sectional review of medical records of patients admitted to hospital between July and September 2010.

Results:

There were 141 PTB suspects. Sputum examination was requested and performed in 67 (48%) suspects, but none were smear-positive. Chest X-ray (CXR) was requested and performed in 26 (39%) suspects whose sputum smears were negative. Eleven suspects had a CXR suggestive of PTB: two were started on TB treatment and eight died before treatment started. Human immunodeficiency virus (HIV) status was known for 50 patients (35% of all suspects) on admission, all of whom were HIV-positive. HIV testing was requested for 37 patients, but was only performed in 12, five of whom were HIV-positive. Only one patient was referred for antiretroviral treatment. There were 41 (29%) deaths, eight of whom had probable TB and were not treated. In the remaining 33 patients who died, only nine (27%) had sputum smears examined and four (12%) had a CXR.

Conclusion:

The study shows inadequacies in the diagnostic management of PTB suspects in the Zomba Central Hospital, but suggests opportunities for improvement.     

Implementing early infant diagnosis of HIV infection at the primary care level: experiences and challenges in Malawi

Problem

Malawi’s national guidelines recommend that infants exposed to the human immunodeficiency virus (HIV) be tested at 6 weeks of age. Rollout of services for early infant diagnosis has been limited and has resulted in the initiation of antiretroviral therapy (ART) in very few infants.

Approach

An early infant diagnosis programme was launched. It included education of pregnant women on infant testing, community sensitization, free infant testing at 6 weeks of age, active tracing of HIV-positive infants and referral for treatment and care.

Local setting

The programme was established in two primary care facilities in Blantyre, Malawi.

Relevant changes

Of 1214 HIV-exposed infants, 71.6% presented for early diagnosis, and 14.5% of those who presented tested positive for HIV. Further testing of 103 of these 126 apparently HIV-positive infants confirmed infection in 88; the other 15 results were false positives. The initial polymerase chain reaction testing of dried blood spots had a positive predictive value (PPV) of 85.4%. Despite active tracing, only 87.3% (110/126) of the mothers of infants who initially tested positive were told their infants’ test results. ART was initiated in 58% of the infants with confirmed HIV infection.

Lessons learnt

Early infant diagnosis of HIV infection at the primary care level in a resource-poor setting is challenging. Many children in the HIV diagnosis and treatment programme were lost to follow-up at various stages. Diagnostic tools with higher PPV and point-of-care capacity and better infrastructures for administering ART are needed to improve the management of HIV-exposed and HIV-infected infants.     

Provider-initiated symptom screening for tuberculosis in Zimbabwe: diagnostic value and the effect of HIV status

Objective

To assess the diagnostic value of provider-initiated symptom screening for tuberculosis (TB) and how HIV status affects it.

Methods

We performed a secondary analysis of randomly selected participants in a community-based TB–HIV prevalence survey in Harare, Zimbabwe. All completed a five-symptom questionnaire and underwent sputum TB culture and HIV testing. We calculated the sensitivity, specificity, and positive and negative predictive values of various symptoms and used regression analysis to investigate the relationship between symptoms and TB disease.

Findings

We found one or more symptoms of TB in 21.2% of 1858 HIV-positive (HIV+) and 9.9% of 7121 HIV-negative (HIV−) participants (P < 0.001). TB was subsequently diagnosed in 48 HIV+ and 31 HIV− participants. TB was asymptomatic in 18 culture-positive individuals, 8 of whom (4 in each HIV status group) had positive sputum smears. Cough of any duration, weight loss and, for HIV+ participants only, drenching night sweats were independent predictors of TB. In HIV+ participants, cough of ≥ 2 weeks’ duration, any symptom and a positive sputum culture had sensitivities of 48%, 81% and 65%, respectively; in HIV− participants, the sensitivities were 45%, 71% and 74%, respectively. Symptoms had a similar sensitivity and specificity in HIV+ and HIV− participants, but in HIV+ participants they had a higher positive and a lower negative predictive value.

Conclusion

Even smear-positive TB may be missed by provider-initiated symptom screening, especially in HIV+ individuals. Symptom screening is useful for ruling out TB, but better TB diagnostics are urgently needed for resource-poor settings.     

Challenges facing HIV treatment in Guinea-Bissau: the benefits of international research collaborations

Problem

The introduction of antiretroviral therapy (ART) for HIV infection in sub-Saharan Africa has improved the quality of life of millions of people and reduced mortality. However, substantial problems with the infrastructure for ART delivery remain.

Approach

Clinicians and researchers at an HIV clinic in Guinea-Bissau identified problems with the delivery of ART by establishing a clinical database and by collaborating with international researchers.

Local setting

The Bissau HIV cohort study group was established in 2007 as a collaboration between local HIV physicians and international HIV researchers. Patients were recruited from the HIV clinic at the country’s main hospital in the capital Bissau.

Relevant changes

Between 2005 and 2013, 5514 HIV-positive patients were treated at the clinic. Working together, local health-care workers and international researchers identified the main problems affecting ART delivery: inadequate drug supply; loss of patients to follow-up; and inadequate laboratory services. Solutions to these problems were devised. The collaborations encouraged local physicians to start their own research projects to find possible solutions to problems at the clinic.

Lessons learnt

The HIV clinic in Bissau faced numerous obstacles in delivering ART at a sufficiently high quality and patients’ lives were put in jeopardy. The effectiveness of ART could be enhanced by delivering it as part of an international research collaboration since such collaborations can help identify problems, find solutions and increase the capacity of the health-care system.     

A ‘one-stop shop’ approach in antenatal care: does this improve antiretroviral treatment uptake in Zimbabwe?

Setting:

Prevention of mother-to-child transmission (PMTCT) programme, Mpilo Hospital antenatal clinic, Zimbabwe.

Objective:

Before and after the introduction of a one-stop shop approach and task-shifting of antiretroviral treatment (ART) to midwives in the PMTCT programme, 1) to compare ART uptake and 2) to determine socio-demographic and other characteristics associated with non-initiation of ART post integration.

Design:

Before and after cohort study.

Results:

A total of 285 women were eligible for ART before the introduction of the one-stop approach and 280 after. Of the 285, 163 (57%) initiated ART before integration; this increased to 244/280 (87%) after integration (RR 1.5, 95% CI 1.4–1.7, P < 0.001). A total of 36 (13%) women did not initiate ART after integration; this was significantly associated with cotrimoxazole uptake (P = 0.03).

Conclusion:

Integrating ART into antenatal care along with task-shifting to midwives considerably increased the uptake of ART. This provides further evidence for scaling up integration rapidly to other facilities in Zimbabwe, and is in line with the vision of a world where no child will be born with the human immunodeficiency virus by 2015.     

Timely HIV Diagnosis and HIV/TB Comanagement Among California Patients in 2008

Objective

National guidelines highlight the roles of early HIV diagnosis and effective comanagement for HIV and tuberculosis (TB) to prevent mortality and morbidity from HIV-related TB. We assessed HIV diagnosis timing and HIV/TB comanagement for California HIV/TB patients.

Methods

We reviewed and analyzed public health charts for California HIV/TB patients reported during 2008. HIV diagnoses fewer than three months before TB diagnosis were considered new HIV diagnoses. We determined the proportion of patients with new HIV diagnoses, risk factors for new HIV diagnoses, and proportion of patients receiving recommended CD4 cell count measurements, supervised TB therapy, and antiretroviral therapy (ART).

Results

Of 130 HIV/TB patients, 51% had new HIV diagnoses. Foreign-born patients were more likely than U.S.-born patients to have new HIV diagnoses. Supervised TB therapy and CD4 cell count measurements followed national recommendations for 91% and 74% of patients, respectively. At least 73% of patients started ART before completing TB therapy. Compared with patients who had previous HIV diagnoses, patients with new HIV diagnoses started ART later and had lower CD4 cell counts and higher viral loads at TB diagnosis.

Conclusions

Although most HIV/TB patients received the recommended treatment, half had new HIV diagnoses. Compared with patients who had previous HIV diagnoses, patients with new HIV diagnoses had greater immunosuppression at TB diagnosis. A new diagnosis indicates that HIV could have been diagnosed earlier and ART or treatment for latent TB infection could have been initiated to prevent TB development.Human immunodeficiency virus (HIV) infection is a potent risk factor for death among tuberculosis (TB) patients.^1–5 In the United States during 2006, HIV-infected patients comprised 12% of TB patients with known HIV status but 30% of patients who died during TB therapy.¹ Among all states, California reported the largest number of TB patients and the second-largest number of patients diagnosed with HIV infection in 2009.^6,7 A field assessment in California found that 132 TB patients had HIV in 2008,⁸ accounting for 14% of all TB patients with HIV in the U.S.⁹Timely HIV diagnosis is an important step in preventing TB disease and HIV/TB mortality. Early HIV diagnosis informs patients of their risk for developing TB disease and triggers opportunities to prevent TB through isoniazid prophylaxis and antiretroviral therapy (ART).¹⁰ Isoniazid prophylaxis effectively reduces the risk of progression to TB disease among HIV-infected patients with latent TB infection (LTBI).¹¹ ART restores immune function and is estimated to reduce the risk of TB in HIV-infected patients by 65%.¹² ART even reduces the TB risk in people without a positive tuberculin skin test, suggesting a possible protective effect against establishment of infection by Mycobacterium tuberculosis.^13,14Even when LTBI progresses to TB disease in patients unaware of their HIV infection, HIV diagnosis is still critical because providers are alerted to patients'' need for ART, which can reduce the risk of death.⁴ Providers can also make referrals to HIV services and coordinate HIV/TB comanagement. Therefore, HIV status determination is recommended for all TB patients.²Once TB patients with HIV infection are identified, effective HIV/TB comanagement is needed to optimize patient outcomes. Recommendations from the Office of AIDS Research Advisory Council (OARAC) help TB clinicians ensure effective comanagement.¹⁵ TB clinicians should obtain cluster of differentiation 4 (CD4) cell counts to monitor HIV progression and determine the timing of ART. Clinicians should also ensure supervision of TB therapy to enhance adherence and prevent acquired TB drug resistance. At the time of the 2008 OARAC recommendations, there was insufficient evidence to determine the optimal timing of ART initiation during TB therapy. Although the 2008 guidelines did not make formal recommendations, they suggested that ART be started two weeks after TB treatment initiation for patients with <100 CD4 cells/millimeter cubed (mm³), eight weeks after TB treatment initiation for patients with 100–200 CD4 cells/mm³, and based on clinical judgment for patients with >200 CD4 cells/mm³.U.S. guidelines highlight the need for early HIV identification and effective HIV/TB comanagement, but little is known about the actual timing of HIV identification or strength of elements of HIV/TB comanagement practices for patients in California. Therefore, we conducted a review of TB patients with HIV (henceforth referred to as HIV/TB patients) reported in California during 2008 to assess the timing of HIV diagnosis and adherence to the 2008 OARAC HIV/TB comanagement recommendations.     

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.     

Characteristics and treatment outcomes of tuberculosis retreatment cases in three regional hospitals,Uganda

Setting:

Three regional referral hospitals in Uganda with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) cases.

Objective:

To determine the treatment outcomes of TB retreatment cases and factors influencing these outcomes.

Design:

A retrospective cohort study of routinely collected National Tuberculosis Programme data between 1 January 2009 and 31 December 2010.

Results:

The study included 331 retreatment patients (68% males), with a median age of 36 years, 93 (28%) of whom were relapse smear-positive, 21 (6%) treatment after failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32 (10%) relapse cases with no smear performed. Treatment success rates for all categories of retreatment cases ranged between 28% and 54%. Relapse smear-positive (P = 0.002) and treatment after failure (P = 0.038) cases were less likely to have a successful treatment outcome. Only 32% of the retreatment cases received a Category II treatment regimen; there was no difference in treatment success among patients who received Category II or Category I treatment regimens (P = 0.73).

Conclusion:

Management of TB retreatment cases and treatment success for all categories in three referral hospitals in Uganda was poor. Relapse smear-positive or treatment after failure cases were less likely to have a successful treatment outcome.     

Nutritional status of HIV-infected women with tuberculosis in Dar es Salaam,Tanzania

Setting:

Tuberculosis (TB) treatment clinics in Dar es Salaam, Tanzania.

Objective:

To quantify anthropometrics and intake of en-ergy and protein among human immunodeficiency virus (HIV) positive women with TB.

Design:

HIV-positive women with newly diagnosed TB were assessed on their anthropometric characteristics and dietary intake. Energy and protein intake were determined using Tanzania food composition tables and compared with standard recommendations. Patients were re-evaluated after 4–6 months of anti-tuberculosis treatment.

Results:

Among 43 women, the baseline median CD4 count was 209 cells/µl (range 8–721); 19 (44%) had a CD4 count of <200; 20 (47%) were on antiretroviral therapy. Body mass index was <18.5 kg/m² in 25 (58%); the median food insecurity score was 6. The median level of kcal/day was 1693 (range 1290–2633) compared to an estimated need of 2658; the median deficit was 875 kcal (range −65–1278). The median level of protein/day was 42 g (range 27–67) compared to 77 g estimated need; the median protein deficit was 35 g (range 10–50). The median weight gain among 29 patients after 4–6 months was 6 kg.

Conclusion:

HIV-positive women with TB have substantial 24-h deficits in energy and protein intake, report significant food insecurity and gain minimal weight on anti-tuberculosis treatment. Enhanced dietary education together with daily supplementation of 1000 kcal with 40 g protein may be required.     

Presumptive diagnosis of severe HIV infection to determine the need for antiretroviral therapy in children less than 18 months of age

Objective

To develop a new algorithm for the presumptive diagnosis of severe disease associated with human immunodeficiency virus (HIV) infection in children less than 18 months of age for the purpose of identifying children who require antiretroviral therapy (ART).

Methods

A conditional probability model was constructed and non-virologic parameters in various combinations were tested in a hypothetical cohort of 1000 children aged 6 weeks, 6 months and 12 months to assess the sensitivity, specificity, and positive and negative predictive values of these algorithms for identifying children in need of ART. The modelled parameters consisted of clinical criteria, rapid HIV antibody testing and CD4+ T-lymphocyte (CD4) count.

Findings

In children younger than 18 months, the best-performing screening algorithm, consisting of clinical symptoms plus antibody testing plus CD4 count, showed a sensitivity ranging from 71% to 80% and a specificity ranging from 92% to 99%. Positive and negative predictive values were between 61% and 97% and between 95% and 96%, respectively. In the absence of virologic tests, this alternate algorithm for the presumptive diagnosis of severe HIV disease makes it possible to correctly initiate ART in 91% to 98% of HIV-positive children who are at highest risk of dying.

Conclusion

The algorithms presented in this paper have better sensitivity and specificity than clinical parameters, with or without rapid HIV testing, for the presumptive diagnosis of severe disease in HIV-positive children less than 18 months of age. If implemented, they can increase the number of HIV-positive children successfully initiated on ART.     

Development and testing of models of tuberculosis contact tracing in rural southern Africa

Setting:

A regional hospital in rural Swaziland.

Objectives:

To evaluate a hospital-based contact screening programme and test approaches to improve its effectiveness.

Design:

An evaluation and quality improvement study of tuberculosis (TB) contact tracing services.

Results:

Hospital-based TB contact tracing led to screening of 157 (24%) of 658 contacts; of these, 4 (2.5%) were diagnosed with TB. Of 68 contacts eligible for human immunodeficiency virus (HIV) testing and counselling, 45 (66%) were tested and 7/45 (16%) were identified as HIV-positive. Twelve (50%) of 24 screened contacts aged <5 years were provided isoniazid prophylaxis. Three enhanced models of TB contact tracing were piloted to screen contacts in the community. Although some enhanced models screened large numbers of contacts, no contacts were diagnosed with TB.

Conclusion:

Contact tracing of household members conducted in TB clinics within hospital settings is effective in high-burden, low-income settings, and can be provided using current resources. Enhanced household contact tracing models that followed up contacts in the community were not found to be effective. Additional resources would be required to provide household TB contact tracing in the community.     

Financial barriers to HIV treatment in Yaound��, Cameroon: first results of a national cross-sectional survey

Objective

To assess the extent to which user fees for antiretroviral therapy (ART) represent a financial barrier to access to ART among HIV-positive patients in Yaoundé, Cameroon.

Methods

Sociodemographic, economic and clinical data were collected from a random sample of 707 HIV-positive patients followed up in six public hospitals of the capital city (Yaoundé) and its surroundings through face-to-face interviews carried out by trained interviewers independently from medical staff and medical questionnaires filled out by prescribing physicians. Logistic regression models were used to identify factors associated with self-reported financial difficulties in purchasing ART during the previous 3 months.

Findings

Of the 532 patients treated with ART at the time of the survey, 20% reported financial difficulty in purchasing their antiretroviral drugs during the previous 3 months. After adjustment for socioeconomic and clinical factors, reports of financial difficulties were significantly associated with lower adherence to ART (odds ratio, OR: 0.24; 95% confidence interval, CI: 0.15–0.40; P < 0.0001) and with lower CD4+ lymphocyte (CD4) counts after 6 months of treatment (OR: 2.14; 95% CI: 1.15–3.96 for CD4 counts < 200 cells/µl; P = 0.04).

Conclusion

Removing a financial barrier to treatment with ART by eliminating user fees at the point of care delivery, as recommended by WHO, could lead to increased adherence to ART and to improved clinical results. New health financing mechanisms based on the public resources of national governments and international donors are needed to attain universal access to drugs and treatment for HIV infection.     

Occupational health policies and practices related to tuberculosis in health care workers in KwaZulu-Natal,South Africa

Setting:

Three district hospitals in KwaZulu-Natal, South Africa, with specialized drug-resistant tuberculosis (TB) wards.

Objective:

To increase understanding of the implementation of occupational health (OH) and infection control (IC) guidelines for the prevention and control of TB among health care workers (HCWs).

Design:

An operational cross-sectional study conducted between July and September 2011, consisting of interviews with OH and IC nurses and chart review of OH medical records.

Results:

Although general national and provincial OH policies are in place, no specific OH policies exist for hospital settings. Two of three hospitals had a full-time OH nurse and all had a full-time IC nurse. All hospitals offered TB symptom screening; however, only 19% of HCWs were screened in 2010. TB incidence among HCWs was 1958 per 100 000 population in 2010. All hospitals offered HIV counseling and testing; however, only 22% of staff were tested across sites. Two hospitals offered isoniazid preventive therapy to HIV-positive staff and reassigned these staff to low TB risk areas.

Conclusions:

While OH policies and procedures are in place, implementation of these policies and procedures is inconsistent. This potentially places HCWs at risk of acquiring TB. These findings support the need for strengthening OH and IC services to prevent TB.