Tuberculosis in HIV programmes in lower-income countries: practices and risk factors

BACKGROUND

Tuberculosis (TB) is a common diagnosis in human immunodeficiency virus (HIV) infected patients on antiretroviral treatment (ART).

OBJECTIVE

To describe TB-related practices in ART programmes in lower-income countries and identify risk factors for TB in the first year of ART.

METHODS

Programme characteristics were assessed using standardised electronic questionnaire. Patient data from 2003 to 2008 were analysed and incidence rate ratios (IRRs) calculated using Poisson regression models.

RESULTS

Fifteen ART programmes in 12 countries in Africa, South America and Asia were included. Chest X-ray, sputum microscopy and culture were available free of charge in respectively 13 (86.7%), 14 (93.3%) and eight (53.3%) programmes. Eight sites (53.3%) used directly observed treatment and five (33.3%) routinely administered isoniazid preventive treatment (IPT). A total of 19 413 patients aged ≥ 16 years contributed 13,227 person-years of follow-up; 1081 new TB events were diagnosed. Risk factors included CD4 cell count (>350 cells/μl vs. <25 cells/μl, adjusted IRR 0.46, 95%CI 0.33-0.64, P < 0.0001), sex (women vs. men, adjusted IRR 0.77, 95%CI 0.68-0.88, P = 0.0001) and use of IPT (IRR 0.24, 95%CI 0.19-0.31, P < 0.0001).

CONCLUSIONS

Diagnostic capacity and practices vary widely across ART programmes. IPT prevented TB, but was used in few programmes. More efforts are needed to reduce the burden of TB in HIV co-infected patients in lower income countries.

Demographic predictors of a positive HIV test result among clients attending a large metropolitan voluntary counselling and testing centre in Thailand

OBJECTIVES

The Thai Red Cross Anonymous Clinic in Bangkok, established in 1991, was the first centre in Asia to provide anonymous, voluntary counselling and testing for HIV infection. We present outcomes of testing for the period 1997-2004.

METHODS

Newcomers to the Thai Red Cross Anonymous Clinic were invited to complete a brief questionnaire concerning HIV risk behaviour and personal characteristics. The questionnaire was linked by code numbers to the HIV test result. Information obtained from the pretest questionnaire and HIV antibody test results from January 1997 to December 2004 were analysed. Data are presented as means [with standard deviation (SD)], medians [with interquartile range (IQR)] or percentages. Multivariate analysis using logistic regression was performed to identify factors predicting a positive HIV test result.

RESULTS

Over the 8-year study period, 65,807 new clients attended the clinic. Two-thirds were male and the mean age was 31.7 years (SD 9 years), and more than half were single. The proportion of high-school graduates was 43%, and 36% earned more than 10,000 Baht a month (40 Baht:1 US dollar). Of 54,578 new clients who had an HIV test during the study period, 17.5% had a positive test result. In multivariate analysis, predictive factors for HIV positivity included female gender, age group 25-34 years, widowed status (women), residence outside Bangkok, birthplace in a northern province, no formal schooling, farmer as profession, and salary less than 5000 Baht a month (the current legal minimum daily wage set by the Thai Ministry of Labor is 181 Baht).

CONCLUSIONS

With nearly 7000 clients newly tested for HIV infection each year, the Anonymous Clinic in Bangkok has provided a unique epidemiological window into the patterns of HIV infection in the Thai capital.

Thai Red Cross zidovudine donation program to prevent vertical transmission of HIV: the effect of the modified ACTG 076 regimen

OBJECTIVES

To evaluate the impact of the modified ACTG 076 zidovudine regimen on the risk for vertical HIV transmission.

DESIGN

Observational retrospective evaluation of a prospective cohort.

SETTING

Thai Red Cross zidovudine donation program to reduce vertical HIV transmission.

PATIENTS

HIV-infected Thai women and their offspring.

INTERVENTION

The modified regimen consisted of 500 mg zidovudine daily during pregnancy and 300 mg zidovudine every 3 h during labor, taken orally, and 2 mg/kg zidovudine syrup four times daily for 6 weeks to infants.

MAIN OUTCOME MEASURES

Only infants with at least 1 HIV DNA polymerase chain reaction (PCR) result at age > or = 4 weeks were included. HIV infection was defined by having at least one positive PCR at age > or = 4 weeks. The transmission rate was calculated. Characteristics of women who did and did not transmit HIV to infants were compared.

RESULTS

A total of 2891 women and their infants participated in the program and 726 infants of 719 women were included in the analysis. Forty-three infants were infected. The overall transmission rate was 6.0% (95% confidence interval, 4.4-8.0). There were no differences in maternal characteristics between transmitters and non-transmitters. The transmission rate in women who started zidovudine before 30 weeks' gestation was not significantly different from that in women who started zidovudine at or after 30 weeks' gestation: 5.7 versus 3.3%, respectively.

CONCLUSIONS

This modified zidovudine regimen is effective in reducing vertical transmission in a country with predominant subtype E infection. A donation program for preventing vertical HIV transmission can be implemented in developing countries, as in Thailand.