Asunto(s)
Infecciones por VIH , Complicaciones Infecciosas del Embarazo , Tuberculosis , Humanos , Brasil/epidemiología , Femenino , Embarazo , Prevalencia , Infecciones por VIH/epidemiología , Complicaciones Infecciosas del Embarazo/epidemiología , Adulto , Tuberculosis/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Among Brazilian initiatives to scale up TB preventive therapy (TPT) are the adoption of the 3HP regimen (12 weekly doses of rifapentine and isoniazid [INH]) in 2021 and the implementation in 2018 of the TPT surveillance information system. Since then, 63% of the 76,000 eligible individuals notified completed TPT. Recommended regimens in this period were 6H, 9H (6 or 9 months of INH) and 4R (4 months of rifampicin).OBJECTIVE: To analyse the factors associated with TPT non-completion.METHODS: We analysed the cohort of TPT notifications from 2018 to 2020. Robust variance Poisson regression model was used to verify the association of TPT non-completion with sociodemographic, clinical and epidemiological variables.RESULTS: Of the 39,973 TPT notified in the study period, 8,534 (21.5%) were non-completed, of which 7,858 (92.1%) were lost to follow-up. Age 15-60 years (relative risk [RR] 1.27, 95% confidence interval [95% CI] 1.20-1.35), TPT with isoniazid (RR 1.40, 95% CI 1.19-1.64) and Black/mixed race (RR 1.17, 95% CI 1.09-1.25) were associated with a higher risk of non-completion.CONCLUSION: Individuals in situations of social and financial vulnerability such as being Black/pardo race, younger and on longer TPT regimens were more likely to be associated with TPT incompletion.
Asunto(s)
Profilaxis Antibiótica , Antituberculosos , Isoniazida , Cumplimiento de la Medicación , Tuberculosis , Adolescente , Adulto , Humanos , Persona de Mediana Edad , Adulto Joven , Población Negra , Brasil/epidemiología , Isoniazida/uso terapéutico , Tuberculosis/prevención & control , Antituberculosos/uso terapéuticoRESUMEN
OBJECTIVE: To estimate the incremental cost-effectiveness of tuberculosis (TB) screening and isoniazid preventive therapy (IPT) among human immunodeficiency virus (HIV) infected adults in Rio de Janeiro, Brazil. DESIGN: We used decision analysis, populated by data from a cluster-randomized trial, to project the costs (in 2010 USD) and effectiveness (in disability-adjusted life years [DALYs] averted) of training health care workers to implement the tuberculin skin test (TST), followed by IPT for TST-positive patients with no evidence of active TB. This intervention was compared to a baseline of usual care. We used time horizons of 1 year for the intervention and 20 years for disease outcomes, with all future DALYs and medical costs discounted at 3% per year. RESULTS: Providing this intervention to 100 people would avert 1.14 discounted DALYs (1.57 undiscounted DALYs). The median estimated incremental cost-effectiveness ratio was $2273 (IQR $1779-$3135) per DALY averted, less than Brazil's 2010 per capita gross domestic product (GDP) of $11,700. Results were most sensitive to the cost of providing the training. CONCLUSION: Training health care workers to screen HIV-infected adults with TST and provide IPT to those with latent tuberculous infection can be considered cost-effective relative to the Brazilian GDP per capita.
Asunto(s)
Antituberculosos/economía , Antituberculosos/uso terapéutico , Coinfección , Costos de los Medicamentos , Infecciones por VIH/economía , Isoniazida/economía , Isoniazida/uso terapéutico , Tuberculosis Latente/tratamiento farmacológico , Tuberculosis Latente/economía , Tamizaje Masivo/economía , Técnicos Medios en Salud/economía , Técnicos Medios en Salud/educación , Técnicas Bacteriológicas/economía , Brasil/epidemiología , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Evaluación de la Discapacidad , Infecciones por VIH/diagnóstico , Infecciones por VIH/epidemiología , Humanos , Capacitación en Servicio/economía , Tuberculosis Latente/diagnóstico , Tuberculosis Latente/epidemiología , Cadenas de Markov , Tamizaje Masivo/métodos , Modelos Económicos , Valor Predictivo de las Pruebas , Evaluación de Programas y Proyectos de Salud , Radiografía Torácica/economía , Factores de Tiempo , Resultado del Tratamiento , Prueba de Tuberculina/economíaRESUMEN
OBJECTIVES: To evaluate the population-based impact of a comprehensive intervention to strengthen tuberculosis (TB) control in Rocinha, the largest urban slum in Rio de Janeiro, Brazil. DESIGN: In July 2003, 40 lay persons were hired and trained as community health workers to supervise treatment, implement educational activities and establish a supportive social network for anti-tuberculosis treatment. Between July 2005 and June 2008, a door-to-door active case finding campaign was conducted. Data were obtained from the Brazilian National Reporting System, which collects information from the TB notification form for every reported case. RESULTS: Between January 2001 and December 2008, 2623 TB cases were reported, 852 before and 1771 after the start of the program. Following the intervention, treatment success rates increased (67.6% vs. 83.2%, P < 0.001) and default rates dropped (17.8% vs. 5.5%, P < 0.001). Compared to the pre-intervention period, the TB case rate declined by an average of 39 cases per 100,000 population per 6 months (P = 0.003) in the post-intervention period, although this may have been due to secular trends already in place at the start of the intervention. Case rates declined from 591/100,000 in 2001 to 496/100,000 in 2008. CONCLUSION: With proper planning and effective community involvement, a successful intervention can lead to high cure rates and may contribute to a decrease in TB notification rates.
Asunto(s)
Antituberculosos/uso terapéutico , Servicios de Salud Comunitaria , Terapia por Observación Directa , Áreas de Pobreza , Tuberculosis/tratamiento farmacológico , Servicios Urbanos de Salud , Poblaciones Vulnerables , Adolescente , Adulto , Brasil/epidemiología , Servicios de Salud Comunitaria/organización & administración , Agentes Comunitarios de Salud , Notificación de Enfermedades , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Incidencia , Masculino , Objetivos Organizacionales , Educación del Paciente como Asunto , Evaluación de Programas y Proyectos de Salud , Apoyo Social , Factores de Tiempo , Resultado del Tratamiento , Tuberculosis/diagnóstico , Tuberculosis/epidemiología , Tuberculosis/transmisión , Servicios Urbanos de Salud/organización & administración , Adulto JovenRESUMEN
BACKGROUND: Antiretroviral therapy (ART) significantly reduces tuberculosis (TB) incidence among persons with human immunodeficiency virus (HIV), but the safety and effectiveness of concomitant treatment for both diseases remain unclear. OBJECTIVE: To evaluate the impact of ART and anti-tuberculosis treatment on survival and risk of adverse events (AE) among co-infected individuals. METHODS: In a retrospective cohort study, clinical data were collected from 618 TB-HIV patients treated with rifampin, isoniazid and pyrazinamide ± ethambutol between 1 January 1995 and 31 December 2003. Patients were categorized into two groups: highly active ART (HAART) or no ART. Different HAART regimens were evaluated. Bivariate analysis, multivariate logistic regression and survival analysis using Cox proportional hazards regression were used. RESULTS: One-year mortality was lower for patients receiving HAART (adjusted hazard ratio [aHR] 0.17, 95%CI 0.09-0.31) compared to no ART. HAART increased the risk of AE (aHR 2.08, 95%CI 1.29-3.36). The odds of AE when receiving a ritonavir + saquinavir HAART regimen was eight-fold higher compared to no ART (OR 8.31, 95%CI 3.04-22.69), while efavirenz-based HAART was not associated with a significantly increased risk of AE (OR 1.42, 95%CI 0.76-2.65). CONCLUSION: HIV patients with TB have significantly better survival if they receive HAART during anti-tuberculosis treatment. Efavirenz-based HAART is associated with fewer AEs than protease inhibitor-based HAART.
Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Antituberculosos/uso terapéutico , Coinfección/tratamiento farmacológico , Infecciones por VIH/tratamiento farmacológico , Adulto , Terapia Antirretroviral Altamente Activa/métodos , Brasil/epidemiología , Coinfección/complicaciones , Coinfección/epidemiología , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , Humanos , Incidencia , Masculino , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Tuberculosis/complicaciones , Tuberculosis/tratamiento farmacológico , Tuberculosis/epidemiologíaRESUMEN
We measured quality of life (QOL) among individuals receiving treatment for human immunodeficiency virus (HIV; n = 45), active tuberculosis (TB; n = 44) and both TB and HIV (n = 9) in Rio de Janeiro, Brazil. Active treated TB was associated with lower physical health (absolute decrease of 0.95 standard deviation in summary score), but not mental health, among people being treated for HIV. Visual analogue scale scores were similar across all three populations, and corresponded closely to standard disability weights used in the literature. Among patients receiving treatment, those with HIV, active TB and both conditions together appear to have similar QOL.
Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Antituberculosos/uso terapéutico , Coinfección , Infecciones por VIH/tratamiento farmacológico , Calidad de Vida , Tuberculosis/tratamiento farmacológico , Adulto , Análisis de Varianza , Brasil , Estudios Transversales , Evaluación de la Discapacidad , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/psicología , Encuestas de Atención de la Salud , Estado de Salud , Humanos , Modelos Lineales , Masculino , Salud Mental , Encuestas y Cuestionarios , Resultado del Tratamiento , Tuberculosis/diagnóstico , Tuberculosis/psicología , Salud UrbanaRESUMEN
SETTING: A large, impoverished squatters' settlement (favela), Rio de Janeiro, Brazil. OBJECTIVE: To assess the community impact of active case finding for tuberculosis (TB) compared to an enhanced case-finding strategy. DESIGN: A pair-matched, cluster-randomized trial comparing household symptom screening and spot sputum collection (Arm 1) vs. distribution of an educational pamphlet (Arm 2) was performed in a large Brazilian favela. We compared TB case-notification rates, time from symptom onset to treatment start and treatment completion proportions between arms. Fourteen neighborhoods (estimated population 58,587) were pair-matched by prior TB case rates and randomly allocated to one of two interventions. TB was diagnosed using acid-fast bacilli smears. New TB cases were interviewed and clinic records were reviewed. RESULTS: A total of 193 TB cases were identified in the 14 study neighborhoods (incidence proportion 329 per 100,000 population). The case identification rate in Arm 1 was 934/100,000 person-years (py) vs. 604/100,000 py in Arm 2 (RR 1.55, 95%CI 1.10-1.99). No significant differences were found in time from cough onset to treatment start or proportion completing treatment. CONCLUSIONS: A door-to-door case-finding campaign was more effective (while ongoing) at detecting prevalent cases and influencing people to come for care than leafleting, but no differences were seen in time to treatment start or treatment completion.
Asunto(s)
Tamizaje Masivo/métodos , Mycobacterium tuberculosis/aislamiento & purificación , Esputo/microbiología , Tuberculosis Pulmonar/diagnóstico , Población Urbana , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Brasil/epidemiología , Niño , Preescolar , Análisis por Conglomerados , Estudios Cruzados , Femenino , Humanos , Incidencia , Lactante , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tuberculosis Pulmonar/epidemiología , Tuberculosis Pulmonar/microbiología , Adulto JovenRESUMEN
SETTING: Central Rio de Janeiro, Brazil. OBJECTIVE: To compare the impact of routine DOTS vs. enhanced DOTS (DOTS-Ampliado or DOTS-A) on tuberculosis (TB) incidence. DESIGN: Cluster-randomized trial in eight urban neighborhoods pair-matched by TB incidence and randomly assigned to receive either the DOTS-A or DOTS strategy. DOTS-A added intensive screening of household contacts of active TB cases and provision of treatment to secondary cases and preventive therapy to contacts with latent TB infection (LTBI) to the standard DOTS strategy. The primary endpoint was the TB incidence rates in communities after 5 years of intervention. RESULTS: From November 2000 to December 2004, respectively 339 and 311 pulmonary TB cases were enrolled and 1003 and 960 household were identified in DOTS and DOTS-A communities. Among contacts from DOTS-A communities, 26 (4%) had active TB diagnosed and treated, 429 (61.3%) had LTBI detected and 258 (60.1%) started preventive therapy. TB incidence increased by 5% in DOTS communities and decreased by 10% in DOTS-A communities, for a difference of 15% after 5 years (P = 0.04). CONCLUSION: DOTS-A was associated with a modest reduction in TB incidence and may be an important strategy for reducing the burden of TB.
Asunto(s)
Antituberculosos/administración & dosificación , Terapia por Observación Directa/métodos , Tuberculosis/prevención & control , Adulto , Antituberculosos/uso terapéutico , Brasil/epidemiología , Trazado de Contacto , Composición Familiar , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Tamizaje Masivo/métodos , Tuberculosis/epidemiología , Población UrbanaRESUMEN
BACKGROUND: Treatment of latent tuberculosis (TB) infection (LTBI) in Brazil is recommended only in the case of contacts of pulmonary smear-positive TB patients aged
Asunto(s)
Portador Sano/epidemiología , Transmisión de Enfermedad Infecciosa/estadística & datos numéricos , Tuberculosis Pulmonar/epidemiología , Tuberculosis Pulmonar/transmisión , Adolescente , Adulto , Antituberculosos/uso terapéutico , Brasil , Portador Sano/diagnóstico , Estudios de Cohortes , Transmisión de Enfermedad Infecciosa/prevención & control , Femenino , Humanos , Incidencia , Isoniazida/uso terapéutico , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Valor Predictivo de las Pruebas , Pirazinamida/uso terapéutico , Estudios Retrospectivos , Rifampin/uso terapéutico , Riesgo , Prueba de Tuberculina , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/tratamiento farmacológico , Adulto JovenRESUMEN
SETTING: A reference hospital for tuberculosis (TB) and human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) with a TB control programme in Rio de Janeiro, Brazil. OBJECTIVE: To estimate the prevalence of resistance to anti-tuberculosis drugs and to identify associated factors. DESIGN: In a cross-sectional study, clinical and laboratory data were collected retrospectively from 2001 to 2005. Patients with isolation of Mycobacterium tuberculosis and available drug susceptibility tests were considered eligible. Data on demographic characteristics, risk factors for resistance, HIV serology and past TB history were collected and analysed by chi(2) Mann-Whitney test and Poisson regression. RESULTS: We analysed 350 treatments, of which 62 were for patients with previous TB. HIV status was positive in 31.2% of cases. Resistance was found in 15.7% and multidrug resistance (MDR) in 4.3% of cases. Previous treatment (P < 0.001) and relapse within 2 years were associated with resistance (P < 0.03). Pulmonary cavities were associated with MDR (P < 0.001). Homelessness was associated with any resistance in newly diagnosed patients (P < 0.01). Working in a hospital was not associated with resistance. CONCLUSION: Suspicion of drug-resistant disease is necessary in patients with a history of previous TB in hospitals in Rio de Janeiro. The implementation of an effective hospital TB control programme can prevent transmission even in high TB prevalence settings.
Asunto(s)
Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Adulto , Brasil/epidemiología , Estudios Transversales , Femenino , Hospitales Urbanos/estadística & datos numéricos , Humanos , Control de Infecciones , Masculino , Persona de Mediana Edad , Análisis Multivariante , Prevalencia , Estudios Retrospectivos , Tuberculosis Resistente a Múltiples Medicamentos/prevención & controlRESUMEN
SETTING: Data from the mortality database, Rio de Janeiro City (RJC) Health Department, Rio de Janeiro, Brazil. OBJECTIVES: To determine the role played by tuberculosis (TB) in Brazil's human immunodeficiency virus (HIV) positive population, we investigated the frequency of TB as the primary cause of death among HIV-positive subjects in RJC. DESIGN: Information about acquired immune-deficiency syndrome (AIDS) deaths from 1996 to 2005 in individuals aged >12 years was obtained from the Mortality Information System (SIM), and the cause of death was classified according to the International Classification of Diseases (ICD-10), through primary causes coded in Chapter I--B20 to B24 (HIV disease). RESULTS: There were 8601 AIDS-related deaths in RJC between 1996 and 2005. TB was the primary cause of death in 9.0% of all AIDS-related deaths, while Pneumocystis carinii pneumonia (PCP) accounted for 4.7%. TB cases erroneously classified under other infectious diseases may have contributed to an underestimation of the number of TB deaths among HIV-positive patients. CONCLUSION: Our study showed that TB is the leading cause of AIDS-related deaths and is responsible for twice as many deaths as PCP, in a scenario of free access to antiretrovirals. The potential benefits of TB preventive treatment and of the availability of highly active antiretroviral treatment could not be established by this analysis.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/mortalidad , Tuberculosis/mortalidad , Síndrome de Inmunodeficiencia Adquirida/epidemiología , Adulto , Antirretrovirales/uso terapéutico , Terapia Antirretroviral Altamente Activa , Brasil/epidemiología , Causas de Muerte , Comorbilidad , Femenino , Infecciones por VIH/epidemiología , Humanos , Masculino , Neumonía por Pneumocystis/epidemiología , Neumonía por Pneumocystis/mortalidad , Tuberculosis/epidemiologíaRESUMEN
SETTING: Rio de Janeiro City, Brazil. OBJECTIVE: To compare community-based directly observed treatment (DOT) for tuberculosis (TB), using community health workers (CHWs), with clinic-based DOT. DESIGN: In a longitudinal study in a cohort of TB patients in a region of Rio de Janeiro city, we evaluated treatment modalities and outcomes in 1811 patients diagnosed with TB between 1 January 2003 and 30 December 2004. Patients were offered DOT when they presented to out-patient clinics for an initial diagnosis. DOT was provided in the clinic or in the community, using CHWs, for patients living in a large favela. Outcomes of treatment were assessed using treatment registry databases. RESULTS: Of the 1811 TB patients, 1215 (67%) were treated under DOT; among these, 726 (60%) received clinic-based treatment and 489 (40%) community-based treatment. Patients offered community-based treatment were more likely to accept DOT (99%) than those offered clinic-based treatment (60%, P<0.001). Treatment success rates for new smear-positive and retreatment TB cases were significantly higher among those treated with community-based DOT compared to clinic-based DOT. CONCLUSION: We conclude that using CHWs to deliver DOT in the community may improve TB treatment outcomes in selected areas such as urban slums.
Asunto(s)
Antituberculosos/administración & dosificación , Servicios de Salud Comunitaria , Terapia por Observación Directa/métodos , Servicio Ambulatorio en Hospital , Áreas de Pobreza , Tuberculosis/tratamiento farmacológico , Adolescente , Adulto , Brasil , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
SETTING: Rio de Janeiro, Brazil, is a middle-income setting with an estimated 1% adult human immunodeficiency virus (HIV) seroprevalence. OBJECTIVE: To examine the cost-effectiveness of DOTS in Rio de Janeiro. DESIGN: Cost-effectiveness analysis based on cost data and an epidemiological model based on programmatic outcomes from the Health Department in Rio de Janeiro, cost data from the retail market sector and epidemiological data from published studies. RESULTS: The 10-year cost of a tuberculosis program treating a population of 262 000 based on self-administered therapy (SAT) was estimated to be $580 271 compared to $1047 886 for DOTS. The largest portion of the DOTS budget was for staff costs and costs incurred by patients, both at 28%. For SAT, the largest percentage of the budget was allocated to medication costs, at 34%. Upgrading from SAT to DOTS averted 1558 cases of tuberculosis (TB, uncertainty range [UR] 1418-1704) and 143 TB deaths (UR 131-155). The incremental cost effectiveness ratio (ICER) for DOTS was $300 per case averted (UR $289-$312) and $3270 per death averted (UR $3123-$3435). In terms of disability adjusted life years (DALYs), DOTS saved 5426 DALYs (UR 4908-5961). The ICER for DOTS was $86 per DALY saved (UR $74-$100). CONCLUSIONS: DOTS is a highly cost-effective intervention in Brazil.
Asunto(s)
Antituberculosos/uso terapéutico , Terapia por Observación Directa/economía , Tuberculosis/tratamiento farmacológico , Brasil/epidemiología , Análisis Costo-Beneficio , Femenino , Seropositividad para VIH/epidemiología , Humanos , Masculino , Prevalencia , Tuberculosis/epidemiología , Población UrbanaRESUMEN
SETTING: Rio de Janeiro City, Brazil. OBJECTIVE: To evaluate the effect of directly observed therapy (DOT) on treatment success, by comparing the treatment success rates between patients treated under DOT with those who received self-administered therapy (SAT). DESIGN: A longitudinal study in a cohort of tuberculosis (TB) patients. Of 9929 new pulmonary TB cases, 1190 (12%) were treated under DOT and 8739 (88%) under SAT. All patients received a three-drug regimen consisting of rifampicin (RMP), isoniazid (INH) and pyrazinamide for 2 months followed by 4 months of RMP and INH. RESULTS: Patients under DOT were more likely to convert to sputum-negative at the end of the second month than those treated under SAT (86.3% vs. 61.9%, P < 0.001). DOT alone was significantly associated with successful treatment (OR 1.6, 95%CI 1.37-1.86, P < 0.001), even when controlled by sex, age and positive smear or culture at enrollment (OR 1.56, 95%CI 1.33-1.82, P < 0.001). CONCLUSION: This pilot DOTS implementation phase showed that DOT is highly effective and feasible in a large urban centre of a developing country.
Asunto(s)
Antituberculosos/uso terapéutico , Terapia por Observación Directa , Tuberculosis Pulmonar/tratamiento farmacológico , Adulto , Brasil , Femenino , Humanos , Estudios Longitudinales , Masculino , Inducción de RemisiónRESUMEN
SETTING: Five medical schools in three cities with different tuberculosis (TB) incidence rates in Rio de Janeiro State, Brazil. OBJECTIVE: To estimate prevalence of and associated factors for latent tuberculosis infection (LTBI) among medical students. DESIGN: A cross-sectional survey was conducted among undergraduate students in pre-clinical, early and late clinical years from schools in cities with low (28/100,000), intermediate (63/100,000) and high (114/100,000) TB incidence rates. Information on socio-demographic profile, previous BCG vaccination, potential TB exposure, co-morbidity and use of respiratory protective masks was obtained. A tuberculin skin test (TST) was performed using the Mantoux technique by an experienced professional. A positive TST, defined as induration > or = 10 mm, was considered LTBI. RESULTS: LTBI prevalence was 6.9% (95%CI 5.4-8.6). In multivariate analysis, male sex (adjusted odds ratio [aOR] 1.8; 95% CI 1.1-3.0), late clinical years (aOR 1.9; 95% CI 1.01-3.5), intermediate TB incidence (aOR 4.3; 95% CI 1.3-14.6) and high TB incidence in the city of medical school (aOR 5.1; 95% CI 1.6-16.8) were significantly associated with LTBI. CONCLUSIONS: The higher prevalence of LTBI in late clinical years suggests that medical students are at increased risk for nosocomial Mycobacterium tuberculosis infection. The implementation of a TB control program may be necessary in medical schools, particularly in cities with higher TB incidence.
Asunto(s)
Infección Hospitalaria , Estudiantes de Medicina , Tuberculosis Pulmonar/epidemiología , Tuberculosis Pulmonar/transmisión , Adulto , Brasil , Estudios Transversales , Educación de Pregrado en Medicina , Femenino , Encuestas Epidemiológicas , Humanos , Incidencia , Control de Infecciones , Masculino , Prevalencia , Factores de RiesgoRESUMEN
We enrolled 427 consecutive patients with tuberculosis diagnosed in Cité Soleil, Haiti in a trial of short-course intermittent therapy. All patients received supervised therapy with isoniazid, rifampin, pyrazinamide, and ethambutol thrice weekly for 8 wk, followed by isoniazid and rifampin thrice weekly for 18 wk. At entry, the 177 human immunodeficiency virus (HIV)-infected patients (42%) were found significantly more likely to have extrapulmonary tuberculosis and negative tuberculin skin tests (p < 0.05). Treatment was well tolerated by both groups of patients, and adherence to the treatment regimen was over 90%. Among patients with pulmonary or intrathoracic tuberculosis, 9% of HIV-seropositive and 1% of HIV-seronegative patients died during therapy (p < 0.001), whereas 81% and 87%, respectively, of those in the two groups were cured. Relapses occurred in 5.4% of HIV-seropositive and 2.8% of HIV-seronegative patients who completed treatment (p = 0.36). Survival after tuberculosis was poorer in HIV-seropositive patients, whose probability of dying was 33% at 18 mo after diagnosis as compared with 3% for HIV-seronegative patients (p < 0.001). HIV-seropositive patients who died had significantly lower median CD4 lymphocyte counts than did HIV-seropositive patients who survived (p < 0.001). Treatment of tuberculosis with short-course, thrice-weekly, supervised therapy in the setting of a developing country is highly efficacious in both HIV-seropositive and -seronegative patients.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Antituberculosos/uso terapéutico , Infecciones por VIH/complicaciones , Tuberculosis Pulmonar/tratamiento farmacológico , Infecciones Oportunistas Relacionadas con el SIDA/mortalidad , Adulto , Antituberculosos/administración & dosificación , Estudios de Casos y Controles , Esquema de Medicación , Quimioterapia Combinada , Femenino , Infecciones por VIH/mortalidad , Seronegatividad para VIH , Seropositividad para VIH , Haití/epidemiología , Humanos , Masculino , Cooperación del Paciente , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento , Tuberculosis Pulmonar/complicaciones , Tuberculosis Pulmonar/mortalidadRESUMEN
The aim of the work reported here was to evaluate community-wide screening for HIV infection that was linked to a tuberculosis control program in a population at high risk for both infections. Between May 1990 and August 1992, adults in Cité Soleil, Haiti, were recruited by community health workers at their homes and in clinics for individual, clinic-based counseling and testing for HIV and tuberculosis. All of the screened subjects were offered post-test HIV counseling. Those with active tuberculosis received treatment, while those with latent tuberculosis and HIV infection were offered an opportunity to participate in a trial of antituberculosis chemoprophylaxis. The 10,611 individuals screened for HIV represented 10.0% of the adult population in Cité Soleil. HIV infection was detected in 1,629 (15.4%) and active tuberculosis in 242 (2.3%). Latent M. tuberculosis infection was found in 4,800 (67.5%) of 7,309 community residents who completed tuberculosis screening, 781 (16.3%) of whom were coinfected with HIV. The high prevalence of HIV infection found in this screened population, as compared to other groups undergoing HIV screening in the same community, suggests that people at high risk for HIV infection selectively sought or accepted tuberculosis clinic screening. Also, many people with active tuberculosis were identified earlier in the course of their disease than they would have been in the absence of a screening program. Overall, the results indicate that community-based screening for HIV infection within a tuberculosis control program can result in effective targeting of screening for both infections.
PIP: Findings are reported from an evaluation of community-wide screening for HIV infection linked to a tuberculosis (TB) control program in a population at high risk for both infections. Between May 1990 and August 1992, adults in Cite Soleil, Haiti, were recruited by community health workers at their homes and in clinics for individual, clinic-based counseling and testing for HIV and TB. All screened subjects were offered post-test HIV counseling. Those with active TB received treatment, while those with latent TB and HIV infection were offered an opportunity to participate in a trial of anti-TB chemoprophylaxis. The 10,611 individuals screened for HIV represented 10.0% of the adult population in Cite Soleil. HIV infection was detected among 1629 (15.4%) and active TB in 242 (2.3%). Latent M. tuberculosis infection was found in 4800 (67.5%) of 7309 community residents who completed TB screening, 781 (16.3%) of whom were coinfected with HIV. The high prevalence of HIV infection in this screened population, compared to other groups screened in the same community, suggests that people at high risk for HIV infection selectively sought or accepted TB clinic screening. Also, many people with active TB were identified earlier in the course of their disease than they would have been in the absence of a screening program. Overall, these results indicate that community-based screening for HIV infection within a TB control program can result in the effective targeting of screening for both infections.
Asunto(s)
Servicios de Salud Comunitaria/organización & administración , Consejo/organización & administración , Infecciones por VIH/prevención & control , Seroprevalencia de VIH , Tamizaje Masivo/organización & administración , Tuberculosis/prevención & control , Adolescente , Adulto , Anciano , Comorbilidad , Femenino , Infecciones por VIH/complicaciones , Haití/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Factores de Riesgo , Tuberculosis/complicacionesRESUMEN
OBJECTIVE: To assess the accuracy of three clinical case definitions for advanced HIV disease: the World Health Organization (WHO) case definition, and the original and revised Caracas case definitions. DESIGN: Retrospective chart review. SETTING: A clinic for patients with all stages of HIV infection at the Johns Hopkins Hospital, Baltimore, [correction of Bethesda] Maryland, USA, a tertiary care university hospital. PATIENTS, PARTICIPANTS: Two hundred and twenty-four HIV-positive adults who underwent initial evaluation between 1 January 1990 and 31 December 1990. MAIN OUTCOME MEASURES: A score for each definition was assigned based on initial evaluation. The sensitivity, specificity, and predictive values were calculated using the Centers for Disease Control (CDC) staging criteria, and results were correlated with total CD4 cell counts. RESULTS: The sensitivities of the WHO, and the original and revised Caracas definitions were 40, 67, and 60%, respectively, using CDC disease stage IV as a positive standard. Specificities were between 99 and 100%, using CDC stage II-III disease as a negative standard. Mean CD4 cell counts for patients with positive scores were 184, 160, and 158 x 10(6)/l, respectively, compared to 191 x 10(6)/l for CDC stage IV patients. Sensitivity was lower when the positive standard was expanded to include all patients with CD4 cell counts less than 200 x 10(6)/l. CONCLUSIONS: In our study population, case definitions were specific, but only moderately sensitive for advanced HIV disease. Prospective studies should be conducted in diverse geographic regions, using lymphocyte or CD4 cell counts when possible.
PIP: The 1st case definition for AIDS was developed by the Centers for Disease Control (CDC) in 1982. WHO adopted CDC definitions for use in some countries and also developed a clinical case definition where HIV serology tests were not feasible. A multivariate analysis of data of Brazilian AIDS patients with positive HIV serology provided the basis for the Caracas definition in 1989 and it subsequent revision. The accuracy of these 3 clinical definitions was evaluated to see their predictive value in an advanced stage of AIDS. The records of 224 HIV-positive adults were reviewed in 1990. Scores were assigned to various symptoms. 80% of men and 20% of women with a median age of 33 years; 1/4 were white and 2/3 were black. 1/3 were homosexuals and 1.2 were iv drug users. 139 were asymptomatic (CDC stage I-II) and 85 were symptomatic (CDC stage IV). 58 patients had total CD4 cell counts of over 500 x 1 million/1; 91 had 200-500 x 1 million/l; and 70 had 200 x 1 million/1. 48 were taking zidovudine and Pneumocytis carinii drugs. The sensitivities of the WHO, original Caracas definition, and revised Caracas definition were 40%, 67%. and 60%, respectively, with 99-100% specificities and positive predictive values of 97-100%. The mean CD4 cell counts for the WHO, original and revised Caracas definitions were 184, 160, and 158 x 1 million/1, respectively, compared with 199 x 1 million/1 of patients with CDC stage IV disease. The predictive values of the 3 definitions for CD4 cell counts 200 x 1 million/1 reached 62%, 73%, and 71% vs. only 59% for CDC stage IV patients. The combination of stage IV symptoms or a CD4 cell count 200 x 1 million/1 produced sensitivities of 31%, 53%, and 47%, respectively, with 100% specificity and positive predictive values. The definitions were highly specific, but only moderately sensitive for advanced AIDS; the Caracas definitions were more sensitive than the WHO definition.