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To exclude tuberculosis, WHO/UNAIDS recommends considering medical history, symptom screen, and chest radiograph before starting tuberculosis prevention in people infected with HIV. The value of a chest radiograph for this purpose is unknown. We prospectively assessed 935 HIV-infected outpatients seeking isoniazid preventive therapy. Of 935 patients, 692 (74%) had no signs or symptoms of tuberculosis. Of these 692, 123 (18%) were lost during the chest radiograph process, and one (0.2%) of the remaining 563 was diagnosed with tuberculosis on the basis of the chest radiograph. A screening chest radiograph should not be required routinely for asymptomatic people taking isoniazid as preventive treatment in settings able to screen for signs and symptoms of tuberculosis.

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SETTING: The World Health Organization recommends that sentinel HIV surveillance be conducted on tuberculosis patients. However, serum HIV testing is complicated in the TB clinic context, and may not be acceptable to patients. DESIGN: To determine the utility of the OraQuick HIV-1/2 Assay for the detection of HIV antibodies in sputum, we consecutively enrolled adult in-patients in Botswana who had sputum sent for acid-fast bacilli testing and serum sent for HIV ELISA testing. OraQuick HIV-1/2 Assay was applied to gingival secretions according to manufacturer's guidelines, and was also dipped into sputum specimens. A subset of 60 sputum specimens was also serially tested up to 72 hours after collection. RESULTS: Of 377 patients, 84% were HIV-positive by serum ELISA. Compared with serum ELISA, the OraQuick HIV-1/2 Assay detected HIV in gingival secretions with 98.4% sensitivity and 98.3% specificity (95%CI 97-99 and 92-100, respectively), and 97.1% sensitivity and 98.3% specificity on initial sputum specimens (95%CI 95-99 and 92-100, respectively). OraQuick HIV-1/2 Assay performance on sputum declined slightly when tested up to 72 hours after collection. CONCLUSIONS: When applied to sputum specimens, the OraQuick HIV-1/2 Assay demonstrates sensitivity and specificity comparable to its intended application on gingival secretions. This novel testing method will be valuable in anonymous sentinel HIV surveillance surveys among tuberculosis patients.

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BACKGROUND: Little is known about causes of death in countries of southern Africa seriously affected by the HIV/AIDS epidemic. METHODS: After obtaining informed consent, autopsies were performed on 128 mainly hospitalised adults in Francistown, Botswana, between July 1997 and June 1998. Criteria for case selection included those who died before a diagnosis could be established, those whose condition deteriorated unexpectedly during hospitalization, and those who had respiratory disease. This represented 14% of adult medical patients who died in hospital during the study period. RESULTS: Of the 128 patients, 104 (81%) were HIV-positive. Among HIV-positive patients, the most common pathologic findings were tuberculosis (TB) (40%), bacterial pneumonia (23%), Pneumocystis carinii pneumonia (11%), and Kaposi's sarcoma (11%); these conditions were the cause of death in 38%, 14%, 11%, and 6%, respectively. Of the 40 pulmonary TB cases, 90% also had disseminated extra-pulmonary TB. Chest radiology could not reliably distinguish the pathologies pre-mortem. CONCLUSIONS: TB was the leading cause of death in our series of HIV-positive adults in Botswana, selected towards those with chest disease; in most, it was widely disseminated. Bacterial pneumonia also played an important role in mortality. Pneumocystis carinii pneumonia was present, but relatively uncommon.

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SETTING: Republic of Botswana. OBJECTIVES: To describe and analyse the epidemiology of adult lung disease in Botswana and provide information about risk factors. DESIGN: Register-based retrospective study. RESULTS: Poverty and human immunodeficiency virus (HIV) infection are major risk factors for lung disease. In 1997, TB caused 15.7%, pneumonia 8.3%, asthma/COPD 0.7% and lung cancer 0.4% of adult in-patient deaths, while 15.5% of deaths were classified as AIDS. Respiratory conditions accounted for 14.2% of hospital admissions and 18.1% of out-patient consultations. Pneumoconiosis was under-reported. Classification problems exist between AIDS, TB and pneumonia. The case fatality rate for in-patients with pneumonia was 5.6% in 1990 vs. 15.5% in 1997, and for TB patients it was 7.4% in 1990 vs. 11.2% in 1997. Morbidity rates also increased for pneumonia and TB through the 1990s. There was a steeper rise in pneumonia mortality and morbidity rates in females than males. The gender distribution in TB incidence remained unchanged, but the average age of female TB patients decreased by 7.7 years from 1983 to 1998, vs. a decrease of 5.3 years in males. CONCLUSIONS: Pulmonary TB and pneumonia are major causes of adult mortality and morbidity in Botswana. Incidences and case fatality rates are increasing, due to co-existent HIV infection. Non-communicable lung diseases are less common causes of death, and prevalences seem to be stable.

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We report the case of a man with chronic myeloid leukaemia, whose disease had undergone transformation and whose life was threatened. Splenectomy was performed, and two years later he is alive and well, taking no anti-leukaemic therapy. Since splenectomy he has had one severe attack of malaria, and one episode of jaundice thought to be due to viral hepatitis. He discontinued his malaria prophylaxis one year ago and has not been ill since. Splenectomy as a last resort will benefit some patients with chronic myeloid leukaemia after transformation, and elective splenectomy should be considered in the management of patients with this disease. However, final unequivocal proof of the value of elective splenectomy is still awaited.

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