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BACKGROUND: The safety and efficacy of nevirapine (NVP) and efavirenz (EFV) based highly active antiretroviral treatment (ART) with concurrent anti-tuberculosis treatment in sub-Saharan Africa has not been well established. METHODS: We performed a retrospective study comparing human immunodeficiency virus (HIV) infected adults exposed and not exposed to tuberculosis (TB) treatment with similar baseline HIV-1 RNA levels who were started on ART as part of Botswana's ART Programme. ART regimens, HIV-1 RNA, CD4+ cell count, and liver function tests were reviewed for 12 months following ART initiation. RESULTS: Among 155 patients on ART only and 155 exposed to TB treatment, there was no difference in virologic or immunologic response throughout the first year of ART. Furthermore, there remained no differences in virologic or immunologic outcomes when NVP and EFV groups were stratified by TB treatment exposure status. While more hepatotoxic events occurred in the group exposed to TB treatment than in those not exposed (9% vs. 3%, P = 0.05), there was no difference between patients treated with NVP and those treated with EFV. CONCLUSIONS: Patients co-infected with HIV and TB in Botswana can be treated effectively with either NVP- or EFV-based ART and TB treatment. As hepatotoxic events were more common in the group exposed to TB treatment, liver function tests should be monitored closely.

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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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The recommended role of ultraviolet germicidal irradiation (UVGI) is to reduce the risk of tuberculosis (TB) transmission in health care facilities. However, excess exposure may result in dermatosis and photokeratitis. In one hospital setting in Botswana, two nurses and one housekeeper complained of eye discomfort, 'like sand in the eyes', after working in an administrative office. The following day, one employee noted facial skin peeling. All symptoms resolved over 2-4 days without sequelae. Six weeks later, the syndrome recurred for all three employees. A workplace investigation revealed that the office had been converted from a hospital sputum induction room, and that an unshielded 36-W UVGI lamp was still installed and operational. The on/off switch for the UVGI lamp was immediately adjacent to the fluorescent bulb on/off switch, and did not have a locking mechanism. The US National Institute for Occupational Safety and Health recommends that exposure to UVGI (254 nm) be less than 6000 microJ/cm2 (6000 microW approximately = sec/cm2) over a daily 8-hour period on unprotected skin or eyes. In the office, UVGI measurements at eye level and looking directly at the UVGI lamp ranged from a low of 20.0 microW approximately = sec/cm2 when seated to a high of 49.9 microW approximately = sec/cm2 when standing. These irradiance levels result in allowable exposure times of 300 and 120 seconds, respectively, and are the most likely cause of the clinical syndrome described.

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