Stable incidence rates of tuberculosis (TB) among human immunodeficiency virus (HIV)-negative South African gold miners during a decade of epidemic HIV-associated TB.

During the last decade, annual tuberculosis (TB) case-notification rates increased 4-fold, to >4000 cases/100000 person-years, in the study workforce, among whom prevalence of human immunodeficiency virus (HIV) was 30% in 2000. Three separate cohort studies, totalling 6454 HIV-negative participants, were combined and analyzed for time trends. Observed incidence of TB varied between 962 (1991-1994) and 1589 (1999-2000) cases/100000 person-years (P=.17, test for trend). There was, however, a progressive increase in age, and, for each period, older age was associated with increased incidence rates of TB (P<.001). Having adjusted for age differences, there was no significant association between incidence of TB and calendar period (P=.81, test for trend). Relative to 1991-1994, multivariate-adjusted incidence-rate ratios were 0.94, for 1995-1997, 0.96, for 1998-1999, and 1.05, for 1999-2000. Preventing a secondary epidemic of TB among HIV-negative individuals may be achievable with conventional means, even in settings with a high burden of HIV-associated TB

Understanding the dynamics of HIV testing services in South African primary care facilities

Facility-based HIV testing services remains underutilized in many settings, including South Africa—even in the context of opt-out testing. Additionally, linkages to care are often not made in a timely manner after an HIV diagnosis, limiting access to ART and the possibility of viral suppression. This brief summarizes findings from formative research conducted by Project SOAR and The Aurum Institute to understand the dynamics of HIV testing services and the key constraints to its optimal delivery

The incidence of tuberculosis among hiv-positive individuals with high CD4 counts: implications for policy

Intensified case finding (ICF) and earlier antiretroviral therapy (ART) initiation are strategies to reduce burden of HIV-associated tuberculosis (TB). We describe incidence of and associated factors for TB among HIV-positive individuals with CD4 counts > 350 cells/μl in South Africa. Prospective cohort study of individuals recruited for a TB vaccine trial. Eligible individuals without prevalent TB were followed up at 6 and 12 months after enrolment. Cox proportional hazards regression was used to determine factors associated with risk of incident TB. Six hundred thirty-four individuals were included in the analysis [80.9 % female, 57.9 % on ART, median CD4 count 562 cells/μl (IQR 466-694 cells/μl)]. TB incidence was 2.7 per 100 person-years (pyrs) (95 % CI 1.6-4.4 per 100 pyrs) and did not differ significantly between those on ART and those not on ART [HR 0.65 (95 % CI 0.24-1.81)]. Low body mass index (BMI <18.5 kg/m(2)) was associated with incident TB [HR 3.87 (95 % CI 1.09-13.73)]. Half of the cases occurred in the first 6 months of follow up and may have been prevalent or incubating cases at enrolment. TB incidence was high and associated with low BMI. Intensified case finding for TB should be strengthened for all HIV positive individuals regardless of their CD4 count or ART statu

Low haemoglobin predicts early mortality among adults starting antiretroviral therapy in an HIV care programme in South Africa: a cohort study

BACKGROUND: Antiretroviral therapy (ART) has dramatically reduced morbidity and mortality among people with HIV infection; however, mortality after the start of ART is high in resource-limited settings. We investigated risk factors for mortality among adults starting ART in a multi-clinic community programme in South Africa. METHODS: Cohort of adults starting ART at 27 clinics between February 2005 and June 2006, followed to 31st March 2007. Kaplan-Meier survival estimates were used to describe overall mortality. Shared frailty Cox regression was used to identify baseline risk factors for early mortality. RESULTS: Among 1350 participants (median age 35.5 years, 60% female, median CD4 count 83/microL [interquartile range (27-147)], median follow-up 13.4 months), there were 185 deaths, overall mortality rate 13/100 pyrs; for 0-3, 3-9 and >9 months from ART start mortality rates were 24, 13 and 6/100 pyrs respectively. 43% of the deaths were in the first 3 months of treatment. Risk factors for mortality in univariable analysis were baseline CD4 count, viral load, haemoglobin and body mass index, in multivariable analysis adjusting for age and gender, only CD4 count and haemoglobin remained independently associated with proportional hazards not being satisfied for haemoglobin. Adjusted hazard ratios (aHR) for participants with haemoglobin 11.9(f)/12.9 (m) g/mL were 4.99, 3.05 and 0.12 respectively comparing to 10-11.9 (f)/12.9 (m)g/mL in the first 3 months of ART. aHRs for CD4 counts were 0.40, 0.38 and 0.34 for 50-99, 100-200 and >200/microL comparing to <50/microL. CONCLUSIONS: The high mortality rate in the first 3 months underlines the need for earlier HIV diagnosis so that ART can be initiated earlier. Low haemoglobin and low CD4 count are both strong predictors of mortality, and could be used to identify individuals at high risk who might benefit from intensive case management

Tuberculosis active case finding: uptake and diagnostic yield among minibus drivers in urban South Africa.

BACKGROUND: Tuberculosis (TB) active case finding is a part of TB control in areas of higher TB prevalence. Congested public transportation settings may be areas of increased TB transmission. We evaluated the uptake and diagnostic yield of an active TB screening program among minibus drivers in a large public transportation facility in Johannesburg, South Africa. METHODS: Over an eight month period, we intensively recruited minibus drivers for TB screening with a goal of 80% uptake among the estimated 2000 drivers. All participants were screened for TB symptoms, offered HIV testing, and had sputum collected for smear microscopy and liquid culture. RESULTS: 686 drivers were screened for TB, representing an uptake of only 34% of all drivers (43% of the target screening). Ten drivers (1.5%) were culture positive for TB, nine of whom were sputum smear microscopy negative. Factors associated with previously undiagnosed TB included a history of incarceration (odds ratio [OR] 5.5, 95% confidence interval: 1.1, 27.3) and HIV positivity (OR 5.3, 95% confidence interval: 1.1, 26.3). CONCLUSIONS: We identified undiagnosed pulmonary TB cases among drivers but at a level that may be insufficient to justify systematic case finding in this population considering the poor uptake

"That is why I stopped the ART": Patients' & providers' perspectives on barriers to and enablers of HIV treatment adherence in a South African workplace programme

BACKGROUND: As ART programmes in African settings expand beyond the pilot stages, adherence to treatment may become an increasing challenge. This qualitative study examines potential barriers to, and facilitators of, adherence to ART in a workplace programme in South Africa. METHODS: We conducted key informant interviews with 12 participants: six ART patients, five health service providers (HSPs) and one human resources manager. RESULTS: The main reported barriers were denial of existence of HIV or of one's own positive status, use of traditional medicines, speaking a different language from the HSP, alcohol use, being away from home, perceived severity of side-effects, feeling better on treatment and long waiting times at the clinic. The key facilitators were social support, belief in the value of treatment, belief in the importance of one's own life to the survival of one's family, and the ability to fit ART into daily life schedules. CONCLUSION: Given the reported uncertainty about the existence of HIV disease and the use of traditional medicines while on ART, despite a programme emphasising ART counselling, there is a need to find effective ways to support adherence to ART even if the individual does not accept biomedical concepts of HIV disease or decides to use traditional medicines. Additionally, providers should identify ways to minimize barriers in communication with patients with whom they have no common language. Finally, dissatisfaction with clinical services, due to long waiting times, should be addressed

TB Fast Track patient cost data

A tabular dataset containing information provided by 99 HIV-positive individuals – men and women aged 18 or above who had a low CD4 count and were not yet on TB or HIV treatment - enrolled in the TB FastTrack trial, a cluster randomised trial to establish the direct and indirect costs of illness incurred at the patient/household level. Data was collected through patient interviews conducted at the health facility where they were receiving treatment in North West Limpopo and Gauteng provinces between June 2014 and March 2015. The dataset contains 450+ variables, including details on quantity of visits, time spent in seeking care, direct medical and non-medical costs incurred, and individual and estimated household income. Household income was established using 4 approaches: (1) self-reported (detail), (2) self-reported (brackets), (3) by matching through an asset index, and (4) national average income

Sensitivity of the lateral flow urine lipoarabinomannan assay in ambulant adults with advanced HIV disease: data from the TB Fast Track study.

BACKGROUND: WHO guidelines recommend the lateral flow urine lipoarabinomannan assay (LF-LAM) for TB diagnosis in hospitalised HIV-positive individuals. The role of LF-LAM among ambulant patients remains less well defined. We investigated the sensitivity of LF-LAM among ambulant HIV-positive adults in primary health clinics in South Africa. METHODS: We enrolled adults (aged ≥18 y) with CD4 counts of ≤150 cells/mm3 who had not received TB treatment or antiretroviral therapy in the preceding 3 or 6 mo, respectively. Research nurses performed the LF-LAM test on freshly voided urine. Results were compared with a reference standard of positive mycobacterial culture (sputum or urine). RESULTS: Of 1505 (54.5% female; median age 37 y; median CD4 count 73 cells/mm3) participants, 973 (64.7%) had a mycobacterial culture result; 105/973 (10.8%) were positive for Mycobacterium tuberculosis. LF-LAM sensitivity was 41.9% (95% CI 32.3 to 51.9%) and 19.0% (95% CI 12.0 to 27.9%) using grade 1+ and grade 2+ cut-off points, respectively. Sensitivity increased with severe immunosuppression and in the presence of poor prognostic indicators (low haemoglobin, body mass index). CONCLUSIONS: When used as the only TB diagnostic test, LF-LAM sensitivity is suboptimal, particularly using the grade 2+ cut-off. More sensitive tests for TB are needed that can be used in primary care settings

Understanding healthcare and population mobility in southern Africa: The case of South Africa

The impact of global increases in human mobility on health systems is a little understood but highly political issue in recipient countries. South Africa (SA) is the greatest recipient of migrants from the Southern African Development Community. There is a policy of free primary health care for all in SA – as outlined in the Constitution and the National Health Act – but its interpretation is less inclusive within implementation guidelines and practice.  As a result, non-nationals face access challenges, and public health responses have engaged with migration to a limited extent. Migration provides opportunities for health and economic benefits, and has the potential to positively and negatively affect health systems. To maximise positive impact and mitigate against potential negative consequences requires attention and engagement of policy-makers from health and other sectors, including public health researchers and health workers. We outline our current research and existing responses to migration and health in southern Africa

Verbal autopsy-assigned causes of death among adults being investigated for TB in South Africa

Aaron S. Karat - ORCID 0000-0001-9643-664X https://orcid.org/0000-0001-9643-664XBackground: Adults being investigated for TB in South Africa experience high mortality, yet causes of death (CoD) are not well defined. We determined CoD in this population using verbal autopsy (VA), and compared HIV- and TB-associated CoD using physician-certified verbal autopsy (PCVA) and InterVA-4 software.Methods: All contactable consenting caregivers of participants who died during a trial comparing Xpert MTB/ RIF to smear microscopy were interviewed using the WHO VA tool. CoD were assigned using PCVA and InterVA-4. Kappa statistic (K) and concordance correlation coefficient (CCC) were calculated for comparison.Results: Among 231 deaths, relatives of 137 deceased were interviewed. Of the 137 deceased 76 (55.4%) were males, median age 41 years (IQR 33–50). PCVA assigned 70 (51.1%) TB immediate CoD (44 [62.8%] pulmonary TB; 26 [37.1%] extra-pulmonary TB); 21 (15.3%) HIV/AIDS-related; and 46 (33.5%) other CoD. InterVA-4 assigned 48 (35.0%) TB deaths; 49 (35.7%) HIV/AIDS-related deaths; and 40 (29.1%) other CoD. Agreement between PCVA and InterVA-4 CoD was slight at individual level (K=0.20; 95% CI 0.10–0.30) and poor at population level (CCC 0.67; 95% CI 0.38–0.99).Conclusions: TB and HIV are leading CoD among adults being investigated for TB. PCVA and InterVA agreement at individual level was slight and poor at population level. VA methodology needs further development where TB and HIV are common.This work was supported by Bill & Melinda Gates Foundation [Grant Number: OPP1034523] for funding the study.https://doi.org/10.1093/trstmh/trw058110pubpub