HIV as a Risk Factor for Multi-Drug Resistant Tuberculosis: A Systematic Review

Winstone Zulu is featured prominently in a tuberculosis (TB) and HIV awareness campaign sponsored by the Stop TB Partnership, a network of organizations, countries and donors that have made the elimination of tuberculosis a priority. He is a Zambian who contracted HIV and later acquired infection with TB. He managed to survive the coinfection when so many around him, including four of his brothers, died of tuberculosis in the 1990s. This defining experience led him to become a leading advocate for TB and HIV patients worldwide. Like those in his family, many people in sub-Saharan Africa and throughout the world who suffer from TB and HIV do not survive the deadly combination. The terrifying consequences of the two infections have now become even graver- a newer threat of multi-drug resistant TB (MDR-TB) jeopardizes what little control there is now over the dual epidemic. Understanding the relationship between HIV and MDR-TB has profound implications for the many people like Winstone Zulu's brothers, who have all but received a death sentence.Master of Public Healt

Is HIV Infection a Risk Factor for Multi-Drug Resistant Tuberculosis? A Systematic Review

BACKGROUND:Tuberculosis (TB) is an important cause of human suffering and death. Human immunodeficiency virus (HIV), multi-drug resistant TB (MDR-TB), and extensive drug resistant tuberculosis (XDR-TB) have emerged as threats to TB control. The association between MDR-TB and HIV infection has not yet been fully investigated. We conducted a systematic review and meta-analysis to summarize the evidence on the association between HIV infection and MDR-TB. METHODS AND RESULTS:Original studies providing Mycobacterium tuberculosis resistance data stratified by HIV status were identified using MEDLINE and ISI Web of Science. Crude MDR-TB prevalence ratios were calculated and analyzed by type of TB (primary or acquired), region and study period. Heterogeneity across studies was assessed, and pooled prevalence ratios were generated if appropriate. No clear association was found between MDR-TB and HIV infection across time and geographic locations. MDR-TB prevalence ratios in the 32 eligible studies, comparing MDR-TB prevalence by HIV status, ranged from 0.21 to 41.45. Assessment by geographical region or study period did not reveal noticeable patterns. The summary prevalence ratios for acquired and primary MDR-TB were 1.17 (95% CI 0.86, 1.6) and 2.72 (95% CI 2.03, 3.66), respectively. Studies eligible for review were few considering the size of the epidemics. Most studies were not adjusted for confounders and the heterogeneity across studies precluded the calculation of a meaningful overall summary measure. CONCLUSIONS:We could not demonstrate an overall association between MDR-TB and HIV or acquired MDR-TB and HIV, but our results suggest that HIV infection is associated with primary MDR-TB. Future well-designed studies and surveillance in all regions of the world are needed to better clarify the relationship between HIV infection and MDR-TB

Factors associated with HIV testing among public sector clinic attendees in Johannesburg, South Africa

Uptake of VCT remains low in many sub-Saharan African countries. Men and women aged 15 and older were recruited from a family planning, STI, and VCT clinic in inner-city Johannesburg between 2004 and 2005 to take part in a cross-sectional survey on HIV testing (n = 198). Fourty-eight percent of participants reported previously testing for HIV and, of these, 86.9% reported disclosing their status to their sex partner. In multivariable analyses, individuals whose partners had been tested for HIV were more likely to have tested (AOR 2.92; 95% CI: 1.38-6.20). In addition, those who reported greater blame/ shame attitudes towards people living with HIV/AIDS were less likely to have tested (AOR 0.35; 95% CI: 0.16- 0.77) while those reporting more equitable attitudes towards people living with HIV/AIDS were more likely to have tested (AOR 2.87; 95% CI: 1.20-6.86). Promotion of and increased access to couples HIV testing should be made available within the South African context

Factors Associated with HIV Testing Among Public Sector Clinic Attendees in Johannesburg, South Africa

Uptake of VCT remains low in many sub-Saharan African countries. Men and women aged 15 and older were recruited from a family planning, STI, and VCT clinic in inner-city Johannesburg between 2004 and 2005 to take part in a cross-sectional survey on HIV testing (n = 198). Fourty-eight percent of participants reported previously testing for HIV and, of these, 86.9% reported disclosing their status to their sex partner. In multivariable analyses, individuals whose partners had been tested; for HIV were more likely to have tested (AOR 2.92 95% CI: 1.38–6.20). In addition, those who reported greater blame/shame attitudes towards people living with HIV/AIDS were less likely to have tested (AOR 0.35; 95% CI: 0.16-0.77) while those reporting more equitable attitudes towards people living with HIV/AIDS were more likely to have tested (AOR 2.87; 95% CI: 1.20-6.86). Promotion of and increased access to couples HIV testing should be made available within the South African context

MDR-TB Prevalence ratio by HIV prevalence among study participants and by region^*.

<p>^*One outlier from the Latin American region (HIV Prevalence: 0.20, Prevalence Ratio: 45) is not presented.</p

Search strategy.

<p>Search strategy.</p

MDR-TB prevalence by HIV status in 32 studies.

*<p>includes patients with unknown HIV status.</p>**<p>all patients have unknown HIV status.</p

Forest plots of acquired (A) and primary (B) MDR-TB prevalence ratios by HIV status and corresponding 95% confidence intervals^*.

<p>^*Clark O; Djulbegovic B. Forest plots in excel software (Data sheet). 2001. Available at <a href="http://www.evidencias.com" target="_blank">www.evidencias.com</a>.</p

Geographic Information System-based Screening for TB, HIV, and Syphilis (GIS-THIS): A Cross-Sectional Study

Abstract Objective: To determine the feasibility and case detection rate of a geographic information systems (GIS)-based integrated community screening strategy for tuberculosis, syphilis, and human immunodeficiency virus (HIV). Design: Prospective cross-sectional study of all participants presenting to geographic hot spot screenings in Wake County, North Carolina. Methods: The residences of tuberculosis, HIV, and syphilis cases incident between 1/1/05-12/31/07 were mapped. Areas with high densities of all 3 diseases were designated &apos;&apos;hot spots.&apos;&apos; Combined screening for tuberculosis, HIV, and syphilis were conducted at the hot spots; participants with positive tests were referred to the health department. Results and Conclusions: Participants (N = 247) reported high-risk characteristics: 67% previously incarcerated, 40% had lived in a homeless shelter, and 29% had a history of crack cocaine use. However, 34% reported never having been tested for HIV, and 41% did not recall prior tuberculin skin testing. Screening identified 3% (8/240) of participants with HIV infection, 1% (3/239) with untreated syphilis, and 15% (36/234) with latent tuberculosis infection. Of the eight persons with HIV, one was newly diagnosed and co-infected with latent tuberculosis; he was treated for latent TB and linked to an HIV provider. Two other HIV-positive persons had fallen out of care, and as a result of the study were linked back into HIV clinics. Of 27 persons with latent tuberculosis offered therapy, nine initiated and three completed treatment. GIS-based screening can effectively penetrate populations with high disease burden and poor healthcare access. Linkage to care remains challenging and will require creative interventions to impact morbidity