Published ahead of print on September 14, 2006, doi:10.1164/rccm.200606-759OC Am. J. Respir. Crit. Care Med., Volume 175, Number 1, January 2007, 87-93 A more recent version of this article appeared on January 1, 2007
Submitted on June 8, 2006 Undiagnosed Tuberculosis in a Community with High HIV-prevalence: Implications for TB ControlRobin Wood1,1 University of Cape Town, Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa, 2 Infectious Diseases Epidemiology Unit, Faculty of Health Sciences, University of Cape Town, School of Public Health and Family Medicine, Cape Town, South Africa; Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, USA, 3 Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom, 4 National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa, 5 University of Cape Town, Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa; Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom, 6 Laboratory of Mycobacterial Immunity and Pathogenesis, Public Health Research Institute, Newark, New Jersey, USA, 7 Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, DHHS, Bethesda, Maryland, USA, 8 The Perinatal Health Research Unit, University of Witwatersrand, Johannesburg, Gauteng, South Africa, 9 University of Cape Town, Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa; The Department of Medicine, University of Cape Town, Cape Town, South Africa * To whom correspondence should be addressed. 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 M.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. Findings. 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. Interpretation 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 strategies based on passive case finding should be supplemented by active case finding targeting HIV-infected individuals. Key words: Pulmonary tuberculosis, incidence and prevalence, HIV-infection, Case finding, African community.
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