Can tuberculosis be controlled?

BACKGROUND: Tuberculosis (TB) is nearly 100% curable. However, the ability of medical and public health interventions to control TB, particularly in developing countries, is often doubted. METHODS: We reviewed data for the amenability of TB to control. We considered separately control of deaths, prevalence, rate of infection and incidence. RESULTS: Tuberculosis mortality can be reduced by more than 80% in less than 5 years. The prevalence of TB can be reduced by 30% or more annually; sustained annual decreases of 17% have been documented in a developing country. The TB infection rate can be reduced by 15% annually. In the absence of human immunodeficiency virus (HIV), TB incidence can be decreased by as much as 25% per year and up to 10% annually in developing countries. A high prevalence of untreated HIV infection in the adult population of a developing country will inevitably result in a significant increase in TB incidence despite optimal use of currently available technologies. CONCLUSIONS: Tuberculosis can be controlled if appropriate policies are followed, effective clinical and public health management is ensured, and there are committed and co-ordinated efforts from within and outside the health sector. However, in the context of a large epidemic of AIDS, TB incidence will inevitably increase. By 2001, less than 30% of global TB cases were reported to have received effective diagnosis, treatment and monitoring. Rapid expansion of effective TB control services is urgently required, both to avert the continued high burden of morbidity and mortality from TB and because of the HIV pandemic.     

Use of telemedicine in the management of infectious diseases

Communication technologies have invaded our daily lives. Several studies have assessed these technologies in the management of infectious diseases (mainly HIV). Weekly short text messages and real-time compliance monitoring assessed in HIV patients are both associated with higher compliance in low-income countries. Virtual consultations to monitor stable chronic HIV patients or tuberculosis treatment in high-income countries appear to be acceptable and efficient. Although assessed in small studies, virtual monitoring seems to reinforce the doctor–patient relationship and the relation between primary care settings and hospitals in various infectious diseases (endocarditis, urinary tract infection, skin and soft tissue infection, HIV, tuberculosis, hepatitis C). A better prevention of infectious diseases (mainly sexually transmitted infections) seems to be observed with telemedicine tools. As fees for teleconsultation or telemonitoring have yet to be defined, the development and evaluation (cost effectiveness) of these tools are difficult. The regulatory framework will need to be improved to encourage such developments, all the while ensuring the confidentiality of data. The development of new tools will require the collaboration of physicians, users, and healthcare systems.     

Clinical research, prophylaxis, therapy, and care for HIV disease in Africa.

By the end of the century, citizens of resource-poor countries will constitute 90% of the world's human immunodeficiency virus (HIV)-infected people. Clinical management of such persons in developing countries has been neglected; most AIDS research has concentrated on epidemiology, and donor agencies have generally invested in the prevention of HIV infection. The heavy burden of HIV disease in Africa requires that care for AIDS be addressed, and prevention and care should be seen as interrelated. Prevention and treatment of tuberculosis, the commonest severe infection in persons with AIDS in Africa, illustrate this interrelationship. We outline priorities for applied research on the management of HIV disease in a resource-poor environment, and discuss prophylaxis, therapy for opportunistic diseases, terminal care, and use of antiretroviral therapy. Research should define the standard of care that can realistically be demanded for HIV disease in a resource-poor environment. Research and public health programs for AIDS in developing countries must address AIDS care and attempt to reduce the widening gap between interventions available for HIV-infected persons in different parts of the world.     

The fight against sexually transmitted diseases in Ivory Coast: what strategies can we use in the face of HIV/AIDS?

In the AIDS era, sexually transmitted diseases (STDs) have become a major health problem in developing countries, particularly in Africa. Delays in the diagnosis and treatment of such infections may result in complications, many of which primarily affect women. Epidemiological studies in Abidjan have shown that more than 10% of the pregnant women attending antenatal clinics present STDs potentially serious for their own health or that of their infants (gonorrhea, chlamydia infection, genital ulcers or active syphilis). There is evidence that STDs increase the transmission of HIV and that improving the syndromic management of STDs reduces the incidence of HIV infection. This provides a strong argument in favor of controlling STDs in areas of high HIV prevalence. In Ivory Coast, as in other African countries, a STD control program has been integrated into the AIDS control program since 1992, as recommended by the World Health Organization. During the first six years of the STD program, considerable progress was made in some areas, but not without difficulty. Simple syndrome-based decision trees have been adopted for the management of STDs in primary health care. Clinical studies have shown these therapeutic algorithms to be effective. At the same time, effective and affordable drugs for treating STDs were added to the list of essential drugs in Ivory Coast, after an international invitation to tender. The entire staff of the public health sector in Abidjan has been trained in syndromic STD management. Training is now being extended to other parts of Ivory Coast, including the private health sector and, in particular, private nurses. The surveillance of syndromic STDs, mainly genital ulcers in both sexes and urethral discharge in men, facilitates monitoring and evaluation of the STD program, following health care activities and adapting orders for drugs for treating STDs to real needs. In the near future, some parts of the STD program will be strengthened, particularly the management of sexual partners of STD patients and reduction of the cost of STD treatment for pregnant women.     

Consequences of adult HIV infection for outpatient morbidity and treatment costs: a prospective study in a factory clinic in Tanzania

Most studies of the medical costs of HIV infection focus on the terminal stage of this chronic illness when the patients have developed AIDS or severe HIV disease and in-patient care dominates. Data are also needed on the medical costs during the prolonged phase of HIV infection preceding severe terminal illness and the effects it may have on the provision of outpatient care. The study population was derived from a cohort study of factory workers and their spouses in Tanzania. Morbidity and outpatient health services utilization are estimated for 1832 adults who on average had been enrolled for two years and utilized the study clinic. Among those who had been enrolled at least 2 years, 50 cases (HIV+ since enrollment) and 150 control (HIV- until last visit) were selected, matched by age, sex and income level to estimate expenditure on drugs by HIV status. There was an increase in morbidity during HIV infection: the incidence of clinical diagnoses was 30% higher among HIV-positive than among HIV-negative adults (p < 0.001). HIV-infected adults also made more frequent use of the outpatient services (23% higher utilization). Estimates of essential drug costs among the subsample showed a 15% increase for HIV infected adults compared to HIV-negative adults, caused by higher use of antibiotics and other antimicrobial drugs. The overall increase in morbidity, outpatient care services utilization and essential drug use due to HIV infection was limited, as HIV prevalence in this adult population was 11%. For example, the net proportion of all illness episodes attributable to HIV infection was 3.2%. Possible biases are discussed and suggest that our findings are a minimum estimate of the effect of adult HIV infection on outpatient care costs. There is a need for more studies in different settings to assess the impact of HIV infection on outpatient care in developing countries.     

Stronger health systems for more effective HIV/AIDS prevention and care

Of the 42 million living with HIV/AIDS world-wide some 90% live in developing countries. The international community acknowledges the devastating impact of HIV/AIDS on development and over the past few years resources to control HIV/AIDS have increased considerably. We argue that strengthening of health systems is a necessary prerequisite for improving the prevention of HIV infection and the care of HIV-infected persons. Sexual behaviour change requires a multidisciplinary approach, but health services play a crucial role in detection and treatment of other sexually transmitted infections; HIV counselling and testing; prevention of mother-to-child transmission of HIV; and care of HIV-infected patients. Increasing access to antiretroviral treatment especially poses formidable challenges to health authorities in developing countries. Additional resources for the prevention of HIV-infection and the care of HIV-infected persons may not have the desired impact if health systems in developing countries are not strengthened. Further, any activity in the area of HIV/AIDS prevention and care, carried out within health services, can have a positive ripple effect on other health care activities and vice versa. This interactive effect needs to be acknowledged and built on.     

Modern information technologies in environmental health surveillance. An overview and analysis

In recent years we have witnessed the massive introduction of new information technologies that are drastically changing the face of our society. These technologies are being implemented en masse in developed countries, but also in some pockets of developing nations as well. They rely on the convergence of several technologies such as powerful and affordable computers, real-time electronic measurement and monitoring devices, massive production of digital information in different formats, and faster, wireless communication media. Such technologies are having significant impacts on every domain of application, including environmental health surveillance. The current paper provides an overview of those technologies that are having or will likely have the most significant impacts on environmental health. They include World Wide Web-based systems and applications, Database Management Systems and Universal Servers, and GIS and related technologies. The usefulness of these technologies as well as the desire to use them further in the future in the context of environmental health are discussed. Expanding the development and use of these technologies to obtain support for global environmental health will require major efforts in the areas of data access, training and support.     

Primary care for HIV-exposed and infected children: translating progress into practice

Recent advances have changed the guidelines for diagnosing and managing pediatric human immunodeficiency virus (HIV) infection. HIV-exposed and HIV-infected children should be evaluated by, or in consultation with, pediatric HIV specialists. Primary care practitioners play a vital role in identification of infants and children at risk for HIV infection and can work collaboratively with pediatric HIV specialists to provide state-of-the-art care. With the use of perinatal zidovudine, perinatal transmission rates have been reduced to 3% to 4%, and they may be reduced even further by the use of combination antiretroviral therapy during pregnancy, viral load monitoring, and obstetric interventions. Diagnosis of HIV infection can be determined in all perinatally infected infants by 6 months of age. Combination antiretroviral therapy is the standard of care for HIV-infected children. It has become increasingly effective, but complex. Families living with HIV are affected by a number of psychosocial issues. Disclosure of HIV diagnosis to a child is an important clinical issue. As HIV-infected children grow older, medical and psychosocial issues may impact school performance. The plan of care to address specific needs of HIV-infected children should be a collaborative effort between the children, their families, the primary care team, and the multidisciplinary pediatric HIV specialty team.     

Diagnosis of paediatric HIV infection in a primary health care setting with a clinical algorithm

OBJECTIVE: To determine the validity of an algorithm used by primary care health workers to identify children with symptomatic human immunodeficiency virus (HIV) infection. This HIV algorithm is being implemented in South Africa as part of the Integrated Management of Childhood Illness (IMCI), a strategy that aims to improve childhood morbidity and mortality by improving care at the primary care level. As AIDS is a leading cause of death in children in southern Africa, diagnosis and management of symptomatic HIV infection was added to the existing IMCI algorithm. METHODS: In total, 690 children who attended the outpatients department in a district hospital in South Africa were assessed with the HIV algorithm and by a paediatrician. All children were then tested for HIV viral load. The validity of the algorithm in detecting symptomatic HIV was compared with clinical diagnosis by a paediatrician and the result of an HIV test. Detailed clinical data were used to improve the algorithm. FINDINGS: Overall, 198 (28.7%) enrolled children were infected with HIV. The paediatrician correctly identified 142 (71.7%) children infected with HIV, whereas the IMCI/HIV algorithm identified 111 (56.1%). Odds ratios were calculated to identify predictors of HIV infection and used to develop an improved HIV algorithm that is 67.2% sensitive and 81.5% specific in clinically detecting HIV infection. CONCLUSIONS: Children with symptomatic HIV infection can be identified effectively by primary level health workers through the use of an algorithm. The improved HIV algorithm developed in this study could be used by countries with high prevalences of HIV to enable IMCI practitioners to identify and care for HIV-infected children.     

Evaluation of HIV/AIDS education in Russia using a video approach

HIV/AIDS has intruded upon the geographic, political, ethnic, gender, and sexual orientation of communities all over the world. As of April 1999, Russia has recorded approximately 13,532 cases of HIV infection. Since the costs of treatment are expensive for many countries, and especially for Russia, educational intervention appears to offer the most effective and affordable solution. A quasi-experimental design, with pre/post tests and intervention (through video education)/control groups, was used to study 20 public schools in St. Petersburg, Russia. Results confirmed the lack of HIV/AIDS education in schools and insufficient information sources from parents, friends, and public health education. ANCOVA statistics demonstrated that use of video education significantly improved students' scores on knowledge and attitudes related to HIV/AIDS prevention. Thus, health educators should consider video education as an effective and efficient tool to present facts to a young audience when they face constraints of shortage of funds, lack of trained teachers, and scarcity of related information.     

President's strategy for AIDS focuses on finding a cure

In December 1996, President Clinton unveiled the first comprehensive national AIDS strategy. The program calls for sustained research funding and better coordination of programs, but offers no dramatic new proposals. The goals for the program include developing cures and preventive vaccines; reducing the number of new HIV cases to zero; guaranteeing access to affordable health care; fighting AIDS-related discrimination; providing continued assistance to other countries; and using current research to develop better treatment programs.     

Leishmaniasis: progress in diagnosis, treatment and prevention

Visceral leishmaniasis ranks second after malaria in the top 10 fatal parasitic diseases worldwide. Treatment is effective, but most patients live in developing countries where even basic health care is unavailable. Economic factors hamper a targeted approach, which should include the following: preventing transmission by distributing bednets; developing diagnostic tools that can be used in the field without a laboratory; developing new and affordable drugs; and evaluating different drug combinations and treatment schedules that may prevent the development of resistance, as has been done in tuberculosis, HIV and malaria.     

Oral lesions in infection with human immunodeficiency virus

This paper discusses the importance of oral lesions as indicators of infection with human immunodeficiency virus (HIV) and as predictors of progression of HIV disease to acquired immunodeficiency syndrome (AIDS). Oral manifestations are among the earliest and most important indicators of infection with HIV. Seven cardinal lesions, oral candidiasis, hairy leukoplakia, Kaposi sarcoma, linear gingival erythema, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis and non-Hodgkin lymphoma, which are strongly associated with HIV infection, have been identified and internationally calibrated, and are seen in both developed and developing countries. They may provide a strong indication of HIV infection and be present in the majority of HIV-infected people. Antiretroviral therapy may affect the prevalence of HIV-related lesions. The presence of oral lesions can have a significant impact on health-related quality of life. Oral health is strongly associated with physical and mental health and there are significant increases in oral health needs in people with HIV infection, especially in children, and in adults particularly in relation to periodontal diseases. International collaboration is needed to ensure that oral aspects of HIV disease are taken into account in medical programmes and to integrate oral health care with the general care of the patient. It is important that all health care workers receive education and training on the relevance of oral health needs and the use of oral lesions as surrogate markers in HIV infection.     

HIV and AIDS in adolescents

HIV infection in adolescents continues to challenge health providers, policymakers, and advocates for youth. There will be no relief from its complexities soon. Primary care providers are in a unique position to use effective HIV prevention and care interventions. Successful programs move beyond moralism to realism. They show a willingness to engage young people and their families in a sensitive dialogue about the needs of youthful sexual development. Youth at high risk for HIV should be identified and referred to comprehensive care and counseling as soon as possible. HIV-positive youth need intensive individual and group interventions to remain healthy and reduce transmission to others. To protect their patient population, health care providers will need to commit time and effort to making adolescents services visible, flexible, affordable, confidential, culturally appropriate, and universally available.     

The global HIV/AIDS pandemic, structural inequalities, and the politics of international health

In spite of recent advances in treatment and care available in most developed countries, the HIV/AIDS pandemic continues to spread throughout the developing world. Structural inequalities continue to fuel the epidemic in all societies, and HIV infection has increasingly been concentrated in the poorest, most marginalized sectors of society in all countries. The relationship between HIV/AIDS and social and economic development has therefore become a central point in policy discussions about the most effective responses to the epidemic. Important progress has been made in recent United Nations initiatives. Maintaining long-term commitment to initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria is especially important in the wake of September 11 and ensuing events, which threaten to redirect necessary resources to seemingly more urgent security concerns.     

TB and AIDS

The Indian National Tuberculosis Survey has indicated that 10 million persons above 5 years of age have pulmonary tuberculosis (TB), of whom 2.5 million are infectious. The annual infection rate amounts to 1.5%. In an average district with a population of 1.5 million, there are about 500 active, infectious TB cases and about 20,000 radiologically active cases. The World Health Organization has declared TB a global health emergency. The pandemic of AIDS had infected 13 million people worldwide by early 1993, and by the year 2000 over 40 million will be infected. In May 1986 only 1 AIDS case was reported, but by May 31, 1994, 728 cases of AIDS and 15,325 cases of HIV infections were reported. At the present rate of infection, there will be 5 million people infected with HIV by 2000 in India. HIV infection is the greatest risk factor for developing TB because of the multiplication of tubercle bacilli in quiescent foci, the progression of dormant infection to disease, and superinfection. The incidence of TB has doubled in the course of 5 years in some countries where HIV is epidemic. 30-70% of TB patients in these countries are estimated to be HIV-positive, imposing significant burden on national health services. On the other hand, efficient health services can still cure TB in HIV-positive patients and forestall the spread of the diseases. One-third of the world's population is infected with TB, and the lives of these people are shortened if they contract HIV. Worse still, for HIV-infected people exposure to TB means death, often within weeks. The only protection against the airborne TB germ is the complete cure of TB patients. At a 1993 conference in London several TB control measures were suggested: national TB control programs offering affordable treatment; faster diagnosis; education and incentives to increase patient compliance; proper drug supplies and quality control; education of influential people; and fight against poverty.     

Measuring the quality of child health care at first-level facilities

Sound policy and program decisions require timely information based on valid and relevant measures. Recent findings suggest that despite the availability of effective and affordable guidelines for the management of sick children in first-level health facilities in developing countries, the quality and coverage of these services remains low. We report on the development and evaluation of a set of summary indices reflecting the quality of care received by sick children in first-level facilities. The indices were first developed through a consultative process to achieve face validity by involving technical experts and policymakers. The definition of evaluation measures for many public health programs stops at this point. We added a second phase in which standard statistical techniques were used to evaluate the content and construct validity of the indices and their reliability, drawing on data sets from the multi-country evaluation of integrated management of childhood illness (MCE) in Brazil, Tanzania and Uganda. The statistical evaluation identified important conceptual errors in the indices arising from the theory-driven expert review. The experts had combined items into inappropriate indicators resulting in summary indices that were difficult to interpret and had limited validity for program decision making. We propose a revised set of summary indices for the measurement of child health care in developing countries that is supported by both expert and statistical reviews and that led to similar programmatic insights across the three countries. We advocate increased cross-disciplinary research within public health to improve measurement approaches. Child survival policymakers, program planners and implementers can use these tools to improve their monitoring and so increase the health impact of investments in health facility care.     

Previous HIV testing among adults and adolescents newly diagnosed with HIV infection - National HIV Surveillance System, 18 jurisdictions, United States, 2006-2009

In 2006, CDC recommended human immunodeficiency virus (HIV) testing for adults, adolescents, and pregnant women in health-care settings and HIV testing at least annually for persons at high risk for HIV infection* to foster early detection, facilitate linkage to care, and improve health outcomes. Understanding previous HIV testing patterns among persons recently diagnosed with HIV infection can help in the design of HIV testing strategies that reduce the time between onset of HIV infection and its diagnosis. To assess previous HIV testing patterns among adults and adolescents newly diagnosed with HIV infection, CDC analyzed data for the period 2006-2009 from 18 jurisdictions participating in HIV incidence surveillance through CDC's National HIV Surveillance System (NHSS).? This report describes the results of that analysis, which indicated that among adults and adolescents for whom testing history information (THI) was available, 41% were diagnosed with HIV infection at their first HIV test, and 59% had a negative test at some point before HIV diagnosis. Groups with the highest percentage of persons testing HIV-negative ≤12 months before HIV diagnosis included those aged 13-29 years (33%), males with HIV transmission attributed to male-to-male sexual contact (29%), and whites (28%). These results demonstrate that many persons diagnosed with HIV infection have never been tested previously. Persons who are unaware of their HIV infection might not change their behavior to reduce the risk for transmission and will not be linked to care, resulting in worse health outcomes. Enhanced efforts are needed to increase annual HIV testing for populations at high risk for HIV infection to increase early detection.     

The potential global market size and public health value of an HIV-1 vaccine in a complex global market

An effective HIV vaccine will be essential for the control of the HIV pandemic. This study evaluated the potential global market size and value of a hypothetical HIV vaccine and considered clade diversity, disease burden, partial prevention of acquisition, impact of a reduction in viral load resulting in a decrease in transmission and delay to treatment, health care system differences regarding access, and HIV screening and vaccination, across all public and private markets. Vaccine product profiles varied from a vaccine that would have no effect on preventing infection to a vaccine that would effectively prevent infection and reduce viral load. High disease burden countries (HDBC; HIV prevalence ≥1%) were assumed to routinely vaccinate pre-sexually active adolescents (10 years old), whereas low disease burden countries (LDBC; HIV prevalence rate <1%) were assumed to routinely vaccinate higher risk populations only. At steady state, routine vaccination demand for vaccines that would prevent infection only was 22–61 million annual doses with a potential market value of $210 million to $2.7 billion, depending on the vaccine product profile. If one-time catch-up campaigns were included (11–14 years old for HDBC and higher risk groups for LDBC), the additional cumulative ∼70–237 million doses were needed over a 10-year period with a potential market value of ∼$695 million to $13.4 billion, depending on the vaccine product profile. Market size and value varied across market segments with the majority of the value in high income countries and the majority of the demand in low income countries. However, the value of the potential market in low income countries is still significant with up to $550 million annually for routine vaccination only and up to $1.7 billion for a one-time only catch-up campaign in 11–14 years old. In the most detail to date, this study evaluated market size and value of a potential multi-clade HIV vaccine, accounting for differences in disease burden, product profile and health care complexities. These findings provide donors and suppliers highly credible new data to consider in their continued efforts to develop an HIV-1 vaccine to address the worldwide disease burden.     

Growth monitoring--inappropriate promotion of an appropriate technology

Growth monitoring has been identified as an important component of the 'Child Survival and Development Revolution'--an initiative advocated by UNICEF and supported by several other development agencies. In this initiative, improvements in the survival of children are attained through the widespread promotion, distribution and utilisation of selected health maintaining technologies by family members. Health workers, community institutions and welfare services help the family by providing encouragement, support and assistance. Growth monitoring has been identified as one of the key technologies--not only because it helps to promote the satisfactory nutrition of children, but also because it provides an opportunity for uniting other low-cost child health interventions. This paper re-examines the importance of widespread growth monitoring as a part of child care in developing countries. In the early sections, reasons for monitoring the growth of children are examined and the role of growth monitoring in primary health care is considered. The rationale for including growth monitoring in the child survival revolution is explored and the potential benefits of growth monitoring are reviewed. The authors then examine the results that have been achieved, to date, in a variety of programmes where child growth is being monitored. They conclude with a re-assessment of the importance of growth monitoring in child care. If the widespread promotion of growth monitoring is being considered as a means to improve the health of a community's children, three key questions must be answered. What are the risks associated with growth faltering or weight loss? To what extent can different health, educational or welfare interventions reduce these risks?(ABSTRACT TRUNCATED AT 250 WORDS)