Tuberculosis screening in an at-risk immigrant Hispanic population in Baltimore city: an academic health center/local health department partnership

Tuberculosis (TB) is endemic and epidemic throughout the world. More people will die of TB this year then in any previous year in modern history. However, in the United States successful TB control programs have resulted in low morbidity and low mortality here. Globalization and immigration threatens this control potentially bringing the infection to a here-to-fore complacent United States. This article describes a unique partnership between a community health program of a School of Nursing and a local health department chest clinic to find, screen and treat a population of Hispanic immigrants otherwise difficult to reach because of legal, language, cultural and socioeconomic barriers. Working through community organizations and limiting, and/or eliminating cultural barriers accomplished a high level of screening and treatment in a population with a significant incidence of latent tuberculosis infection. The program was of great satisfaction to the students and faculty involved; the personnel of a seriously under-financed health department and the community participants involved.     

Adherence to highly active antiretroviral therapy assessed by pharmacy claims predicts survival in HIV-infected South African adults

It is unclear how adherence to highly active antiretroviral therapy (HAART) may best be monitored in large HIV programs in sub-Saharan Africa where it is being scaled up. We aimed to evaluate the association between HAART adherence, as estimated by pharmacy claims, and survival in HIV-1-infected South African adults enrolled in a private-sector AIDS management program. Of the 6288 patients who began HAART between January 1999 and August 2004, 3805 (61%) were female and 6094 (97%) were black African. HAART adherence was >or=80% for 3298 patients (52%) and 100% for 1916 patients (30%). Women were significantly more likely to have adherence>or=80% than men (54% vs 49%, P<0.001). The median (interquartile range) follow-up time was 1.8 (1.37-2.5) years. As of 1 September 2004, 222 patients had died-a crude mortality rate of 3.5%. In a multivariate Cox regression model, adherence<80% was associated with lower survival (relative hazard 3.23; 95% confidence interval: 2.37-4.39). When medication adherence was divided into 5 strata with a width of 20% each, each stratum had lower survival rates than the adjacent, higher-adherence stratum. Among other variables tested, only baseline CD4+ T-cell count was significantly associated with decreased survival in multivariate analysis (relative hazard 5.13; 95% confidence interval: 3.42-7.72, for CD4+ T-cell count200 cells/microL). Pharmacy-based records may be a simple and effective population-level tool for monitoring adherence as HAART programs in Africa are scaled up.