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Undiagnosed Tuberculosis in a Community with High HIV Prevalence

Implications for Tuberculosis Control

Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine; Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, and Department of Medicine, University of Cape Town; National Health Laboratory Services, Groote Schuur Hospital, Cape Town; Perinatal Health Research Unit, University of Witwatersrand, Johannesburg, South Africa; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York; Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Laboratory of Mycobacterial Immunity and Pathogenesis, Public Health Research Institute, Newark, New Jersey; and Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland

Correspondence and requests for reprints should be addressed to Linda-Gail Bekker, M.B.Ch.B., F.C.P.(S.A.), Ph.D., The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Health Science Faculty, UCT Observatory, Cape Town 7925, South Africa. E-mail: linda-gail.bekker{at}hiv-research.org.za

Background: Although failure of tuberculosis (TB) control in sub-Saharan Africa is attributed to the HIV epidemic, it is unclear why the directly observed therapy short-course (DOTS) strategy is insufficient in this setting. We conducted a cross-sectional survey of pulmonary TB (PTB) and HIV infection in a community of 13,000 with high HIV prevalence and high TB notification rate and a well-functioning DOTS TB control program.

Methods: Active case finding for PTB was performed in 762 adults using sputum microscopy and Mycobacterium tuberculosis culture, testing for HIV, and a symptom and risk factor questionnaire. Survey findings were correlated with notification data extracted from the TB treatment register.

Results: Of those surveyed, 174 (23%) tested HIV positive, 11 (7 HIV positive) were receiving TB therapy, 6 (5 HIV positive) had previously undiagnosed smear-positive PTB, and 6 (4 HIV positive) had smear-negative/culture-positive PTB. Symptoms were not a useful screen for PTB. Among HIV-positive and -negative individuals, prevalence of notified smear-positive PTB was 1,563/100,000 and 352/100,000, undiagnosed smear-positive PTB prevalence was 2,837/100,000 and 175/100,000, and case-finding proportions were 37 and 67%, respectively. Estimated duration of infectiousness was similar for HIV-positive and HIV-negative individuals. However, 87% of total person-years of undiagnosed smear-positive TB in the community were among HIV-infected individuals.

Conclusions: PTB was identified in 9% of HIV-infected individuals, with 5% being previously undiagnosed. Lack of symptoms suggestive of PTB may contribute to low case-finding rates. DOTS strategy based on passive case finding should be supplemented by active case finding targeting HIV-infected individuals.

Key Words: African community • case finding • HIV infection • incidence and prevalence • pulmonary tuberculosis

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject The complex interaction between the dual HIV and TB epidemics at a community level is underreported. What This Study Adds to the Field Pulmonary tuberculosis is common in HIV-infected individuals. Specific active case finding strategies need to be targeted at HIV-infected individuals.

 

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