HIV-Associated Tuberculosis: Diagnostic and Treatment Challenges

Tuberculosis (TB) and the human immunodeficiency virus (HIV) are, individually, two of the world's greatest ongoing public health threats. In combination, the two diseases can be even more devastating. HIV significantly increases an individual's chances of reactivation of latent TB infection and progression to active TB disease. HIV's associated immunosuppression makes it more difficult to diagnose active TB due to a higher likelihood of atypical and extrapulmonary presentation and poorer performance of standard diagnostic tools. TB is the major cause of death in individuals infected with HIV, and the combination of both illnesses creates unique treatment challenges for providers due to interactions between antituberculous and antiretroviral medications, overlapping drug toxicities, and the immune reconstitution inflammatory syndrome. Magnifying these challenges even further is the fact that much of the burden of TB/HIV coinfection exists in some of the world's most resource-limited settings. Concerted efforts are needed to identify rapid and accurate diagnostic tools for active TB disease and latent TB infection (LTBI) that are practical and inexpensive and that perform well in individuals with HIV infection. Also needed are effective and feasible strategies to optimize management of both conditions in the coinfected patient

Expanding access to antiretroviral therapy through the public sector--the challenge of retaining patients in long-term primary care.

The growing movement to make antiretroviral therapy (ART) widely available in South Africa has spurred discussion on different aspects of delivering HIV treatment services, deliberations that have taken on new importance in light of the national government’s recent announcement of a plan to make ART widely available in the public sector. Yet one critical aspect of delivering ART effectively within HIV care services has received surprisingly little attention, namely the challenge of retaining patients in long-term programmes of primary care. Here we discuss the importance of distinguishing adherence to medications from retention in care, as well as the possible interventions that may be employed to improve long-term patient retention

The President's Emergency Plan for AIDS Relief — Is the Emergency Over?

In his 2003 State of the Union Address, President George W. Bush asked Congress to commit $15 billion over the next 5 years for the President's Emergency Plan for AIDS Relief (PEPFAR) to combat the global epidemic of human immunodeficiency virus (HIV) infection. Thus was launched one of the largest international health-assistance programs in history. PEPFAR has since been both condemned as unilateral, paternalistic, narrowly focused, and distorted by a political agenda and lauded as groundbreaking, visionary, effective, and responsible for saving hundreds of thousands of lives. This year, Congress has had to consider the reauthorization of the program. On July 16, the Senate approved legislation that would increase the funding to$48 billion for the next 5 years, sending the measure into conference committee. Thus, this seems an appropriate time to examine PEPFAR's achievements, limitations, and lessons for the future

Clinical trials provide the evidence critical for patient empowerment

In this issue of the Journal, Delva et al. discuss in a Viewpoint our Perspective article published in the New England Journal of Medicine in which we argue for the urgent need for a clinical trial on when to initiate antiretroviral therapy (ART) in HIV-infected patients in sub-Saharan Africa. The authors posit that there is currently sufficient evidence to make informed decisions regarding this issue and consequently individual patients’ autonomy should be the key factor in determining the timing for ART initiation

When to Start ART in Africa — An Urgent Research Priority

The history of the HIV–AIDS epidemic was profoundly altered by the introduction of antiretroviral therapy (ART). More than 8 million people in low-income and middle-income countries have received lifesaving ART over the past decade, yet in 2011 an estimated 34 million people were living with HIV infection, 6.8 million were eligible for treatment but lacked access to ART, 2.5 million became newly infected, and 1.7 million died of HIV-related disease

Expanding access to antiretroviral therapy through the public sector- the challenge of retaining patients in long-term primary care

The growing movement to make antiretroviral therapy (ART) widely available in South Africa has spurred discussion on different aspects of delivering HIV treatment services,1 2 deliberations that have taken on new importance in light of the national government’s recent announcement of a plan to make ART widely available in the public sector. Yet one critical aspect of delivering ART effectively within HIV care services has received surprisingly little attention, namely the challenge of retaining patients in long-term programmes of primary care. Here we discuss the importance of distinguishing adherence to medications from retention in care, as well as the possible interventions that may be employed to improve long-term patient retention

When to Start ART in Africa — An Urgent Research Priority

The history of the HIV–AIDS epidemic was profoundly altered by the introduction of antiretroviral therapy (ART). More than 8 million people in low-income and middle-income countries have received lifesaving ART over the past decade, yet in 2011 an estimated 34 million people were living with HIV infection, 6.8 million were eligible for treatment but lacked access to ART, 2.5 million became newly infected, and 1.7 million died of HIV-related disease

Underreported injection drug use and its potential contribution to reported increase in sexual transmission of HIV in Kazakhstan and Kyrgyzstan

Background We conducted a cross-sectional integrated bio-behavioral survey among sex partners of persons who inject drugs (PWID) to explore reasons for reported increase in reporting of heterosexually transmitted HIV in Kazakhstan and Kyrgyzstan. Methods Sexual partners of PWID were recruited through PWID. Behavioral data were collected through semi-structured interviews. Dried blood spots were obtained and tested for HIV and hepatitis C virus antibodies (HCVAb). Descriptive univariate and bivariate analyses, and multivariate analyses using logistic regression modeling were performed to identify factors associated with HIV and HCV infections. Results Among 1982 sex partners of PWID, overall HIV prevalence was 6.4%; 5.1% and 12.9% among those reported never and ever injecting drugs, respectively (p < 0.001). Overall, HCVAb prevalence was 21.3%; 15.0% and 53.9% among those reported never and ever injecting drugs, respectively (p < 0.001). Of HCV-positive participants, 58% and 34% (p < 0.001) reported prior history of injecting drug use among men and women, respectively. HIV prevalence was lower among HCV-negative (4.2%) compared to HCV-positive participants (14.4%) (p < 0.001). HIV prevalence was 3.5% (95%CI = 2.4–4.6) in a subset of female participants with no reported prior injecting drug use history and who were HCVAb-negative and did not report having an HIV-positive sex partner. Participant sex and number of sex partners as well as use of condoms in the past 12 months were not associated with HIV seropositivity. Conclusions High prevalence of HCV among sex partners of PWID who denied ever injecting drugs suggests underreporting of injecting practices. The increased attribution of HIV infection to sexual transmission based on self-report may be partly explained by underreporting of injection drug use due to stigmatization of this behavior

Letting HIV Transform Academia — Embracing Implementation Science

The human immunodeficiency virus (HIV) epidemic has had an extraordinary global impact. Even as it has devastated societies, it has also inspired community empowerment, motivated impressive scientific discoveries, and provoked an unprecedented mobilization of vast resources for a single health condition. Not yet fully realized, however, is the epidemic's potential for expanding the core mission of academic institutions to include the pursuit of a wider range of research