BACKGROUND: Tuberculosis (TB) screening affords clinicians opportunities to diagnose or exclude TB disease and initiate Isoniazid Preventive Therapy (IPT) for people living with HIV (PLHIV). METHODS: We implemented an algorithm to diagnose or rule out TB among PLHIV in eleven HIV clinics in Thailand and Vietnam. We assessed algorithm yield and uptake of IPT and factors associated with TB disease among PLHIV. RESULTS: A total of 1,448 PLHIV not yet on antiretroviral therapy (ART) were enrolled and screened for TB. Overall, 634 (44%) screened positive and 119 (8%) were diagnosed with TB; of these, 40% (48/119) were diagnosed by a positive culture following a negative sputum smear microscopy. In total, 55% of those eligible (263/477) started on IPT and of those, 75% (196/263) completed therapy. The prevalence of TB disease we observed in this study was 8.2% (8,218 per 100,000 persons): 46 and 25 times the prevalence of TB in the general population in Thailand and Vietnam, respectively. Several factors were independently associated with TB disease including being underweight (aOR [95% CI]: 2.3 [1.2, 2.6]) and using injection drugs (aOR [95% CI]: 2.9 [1.3, 6.3]). CONCLUSIONS: The high yield of TB disease diagnosed among PLHIV screened with the algorithm, and higher burden among PLHIV who inject drugs, underscores the need for innovative, tailored approaches to TB screening and prevention. As countries adopt Test-and-Start for ART, TB screening, sensitive TB diagnostics, and IPT should be included in differentiated-care models for HIV to improve diagnosis and prevention of TB among PLHIV.

SETTING: National Tuberculosis (TB) Program sites in northwest Cambodia. OBJECTIVE: To evaluate the impact of Xpert((R)) MTB/RIF at point of care (POC) as compared to non-POC sites on the diagnostic evaluation of people living with the human immunodeficiency virus (PLHIV) with TB symptoms and patients with possible multidrug-resistant (MDR) TB. DESIGN: Observational cohort of patients undergoing routine diagnostic evaluation for TB following the rollout of Xpert. RESULTS: Between October 2011 and June 2013, 431 of 822 (52%) PLHIV with TB symptoms and 240/493 (49%) patients with possible MDR-TB underwent Xpert. Xpert was more likely to be performed when available as POC. A smaller proportion of PLHIV at POC sites were diagnosed with TB than at non-POC sites; however, at POC sites, a higher proportion of those diagnosed with TB were bacteriologically positive. There was poor agreement between Xpert and other tests such as smear microscopy and culture. Overall, the evaluation of patients with possible MDR-TB increased following Xpert rollout, yet for patients confirmed as having drug resistance on drug susceptibility testing, only 46% had rifampin resistance that would be identified with Xpert. CONCLUSION: Although utilization of Xpert was low, it may have contributed to an increase in evaluations for possible MDR-TB and a decline in empiric treatment for PLHIV when available as POC.

Although widespread Ebola transmission has been controlled in west Africa, the indirect consequences of the recent epidemic could be yet to fully manifest. In the past 2 years, management of other diseases in Sierra Leone, Liberia and Guinea has been limited as resources were focused on the Ebola response. HIV and tuberculosis programmes were among those affected by workforce depletion, closure of health facilities, and interrupted service and supply chains, leading to a worsening of the region’s HIV and tuberculosis epidemics.1–3 These epidemics were major public health problems in those three countries before the Ebola outbreak: in 2013, 11,200 people died of AIDS-related causes and 7,900 died from tuberculosis. Fewer than two thirds of tuberculosis cases were diagnosed and only 30–57% of eligible people living with HIV were on antiretroviral therapy (ART) – largely due to health system challenges including uncoordinated mobilisation of scarce resources, insufficient staff and laboratory capacity, and inadequate data collection and management.4–7 | Although the Ebola crisis exacerbated many of these problems, it also provides an unprecedented opportunity to assess and address pre-existing and anticipated health challenges in the worst-affected countries. Although there have been multiple calls to heed lessons from the global HIV and tuberculosis responses when addressing Ebola,8–10 we now have a unique chance to transition several elements of the Ebola response to rebuild and strengthen HIV and tuberculosis systems in the region, while sustaining capacity for emergency response.

BACKGROUND: In 2005, Rwanda drafted a national TB/HIV policy and began scaling-up collaborative TB/HIV activities. Prior to the scale-up, we evaluated existing TB/HIV practices, possible barriers to policy and programmatic implementation, and patient treatment outcomes. We then used our evaluation data as a baseline for assessing the national scale-up of collaborative TB/HIV activities from 2005 through 2009. METHODS: Our baseline evaluation included a cross-sectional evaluation of 23/161 TB clinics. We conducted structured interviews with patients and clinic staff and then reviewed TB registers and patient records to assess HIV testing practices, provision of HIV care and treatment for people with TB that tested positive for HIV, and patients' TB treatment outcomes. Following our baseline evaluation, we used nationally representative TB/HIV surveillance data to monitor the scale-up of collaborative TB/HIV activities. RESULTS: Of 207 patients interviewed, 76% were offered HIV testing, 99% accepted, and 49% reported positive test results. Of 40 staff interviewed, 68% reported offering HIV testing to >50% of patients. From 2005-2009, scale-up of TB/HIV activities resulted in increased HIV testing of patients with TB (69% to 97%) and for patients with TB disease and HIV infection (TB/HIV) increases in provision of cotrimoxazole (15% to 92%) and antiretroviral therapy (13% to 49%). The risk of death among patients with TB/HIV relative to patients with TB not infected with HIV declined from 2005 (RR=6.1, 95%CI 2.6, 14.0) to 2007 (RR=1.8, 95%CI 1.68, 1.94). CONCLUSIONS: Our baseline evaluation highlighted that staff and patients were receptive to HIV testing. However, expanded access to testing, care, and treatment was needed based on the proportion of patients with TB having unknown HIV status and the high rate of HIV infection and poorer TB treatment outcomes for patients with TB/HIV. Following our evaluation, scale-up of TB/HIV services resulted in almost all patients with TB knowing their HIV status. Routine HIV testing allowed for dramatic increases in the uptake of lifesaving HIV care and treatment coinciding with a decline in the risk of death among patients with TB/HIV.

OBJECTIVES: We investigated a cluster of tuberculosis (TB) cases among persons using methamphetamines in Snohomish County, Washington, to determine the extent of the outbreak, examine whether methamphetamine use contributed to TB transmission, and implement strategies to prevent further infections. METHODS: We screened contacts to find and treat persons with TB disease or infection. We then formed a multidisciplinary team to engage substance abuse services partners and implement outreach strategies including novel methods for finding contacts and a system of incentives and enablers to promote finding, screening, and treating patients with TB and their infected contacts. RESULTS: We diagnosed and completed treatment with 10 persons with TB disease. Eight of 9 adult patients and 67% of their adult contacts reported using methamphetamines. Of the 372 contacts, 319 (85.8%) were screened, 80 (25.1%) were infected, 71 (88.8%) started treatment for latent infection, and 57 (80.3%) completed treatment for latent infection. CONCLUSIONS: Collaborative approaches integrating TB control, outreach, incentives, and enablers resulted in high rates of treatment adherence and completion among patients and infected contacts. TB control programs should collaborate with substance abuse programs to address addiction, overcome substance abuse-related barriers to treatment, treat TB, and prevent ongoing transmission.