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BackgroundSince 2011, WHO has recommended that HIV-positive inpatients be routinely screened for tuberculosis with the WHO four-symptom screen (W4SS) and, if screened positive, receive a molecular WHO-recommended rapid diagnostic test (eg, Xpert MTB/RIF [Xpert] assay). To inform updated WHO tuberculosis screening guidelines, we conducted a systematic review and individual participant data meta-analysis to assess the performance of W4SS and alternative screening tests to guide Xpert testing and compare the diagnostic accuracy of the WHO Xpert algorithm (ie, W4SS followed by Xpert) with Xpert for all HIV-positive inpatients.MethodsWe searched MEDLINE, Embase, and Cochrane Library from Jan 1, 2011, to March 1, 2020, for studies of adult and adolescent HIV-positive inpatients enrolled regardless of tuberculosis signs and symptoms. The separate reference standards were culture and Xpert. Xpert was selected since it is most likely to be the confirmatory test used in practice. We assessed the proportion of inpatients eligible for Xpert testing using the WHO algorithm; assessed the accuracy of W4SS and alternative screening tests or strategies to guide diagnostic testing; and compared the accuracy of the WHO Xpert algorithm (W4SS followed by Xpert) with Xpert for all. We obtained pooled proportion estimates with a random-effects model, assessed diagnostic accuracy by fitting random-effects bivariate models, and assessed diagnostic yield descriptively. This systematic review has been registered on PROSPERO (CRD42020155895).FindingsOf 6162 potentially eligible publications, six were eligible and we obtained data for all of the six publications (n=3660 participants). The pooled proportion of inpatients eligible for an Xpert was 90% (95% CI 89-91; n=3658). Among screening tests to guide diagnostic testing, W4SS and C-reactive protein (≥5 mg/L) had highest sensitivities (≥96%) but low specificities (≤12%); cough (≥2 weeks), haemoglobin concentration (2), and lymphadenopathy had higher specificities (61-90%) but suboptimal sensitivities (12-57%). The WHO Xpert algorithm (W4SS followed by Xpert) had a sensitivity of 76% (95% CI 67-84) and specificity of 93% (88-96; n=637). Xpert for all had similar accuracy to the WHO Xpert algorithm: sensitivity was 78% (95% CI 69-85) and specificity was 93% (87-96; n=639). In two cohorts that had sputum and non-sputum samples collected for culture or Xpert, diagnostic yield of sputum Xpert was 41-70% and 61-64% for urine Xpert.InterpretationThe W4SS and other potential screening tests to guide Xpert testing have suboptimal accuracy in HIV-positive inpatients. On the basis of these findings, WHO now strongly recommends molecular rapid diagnostic testing in all medical HIV-positive inpatients in settings where tuberculosis prevalence is higher than 10%.FundingWorld Health Organization.

The World Health Organization (WHO) recommends providing tuberculosis preventive treatment (TPT) to all persons living with HIV and to all household contacts of persons with bacteriologically confirmed pulmonary tuberculosis disease. Regrettably, the absence of a harmonized data collection and management approach to TPT indicators has contributed to programmatic challenges at local, national, and global levels. However, in April 2020, the WHO launched the Consolidated HIV Strategic Information Guidelines, with an updated set of priority indicators. These guidelines recommend that Ministries of Health collect, report, and use data on TPT completion in addition to TPT initiation. Both indicators are reflected in the WHO’s list of 15 core indicators for program management and are also required by the US President’s Emergency Plan for AIDS Relief’s Monitoring, Evaluation, and Reporting (MER) guidance. Although not perfectly harmonized, both frameworks now share essential indicator characteristics. Aligned indicators are necessary for robust strategic and operational planning, resource allocation, and data communication. “Collect once, use many times” is a best practice for strategic information management. Building harmonized and sustainable health systems will enable countries to successfully maintain essential HIV, tuberculosis, and other health services while combatting new health threats.

Background: The WHO-recommended tuberculosis screening and diagnostic algorithm in ambulatory people living with HIV is a four-symptom screen (known as the WHO-recommended four symptom screen [W4SS]) followed by a WHO-recommended molecular rapid diagnostic test (eg Xpert MTB/RIF [hereafter referred to as Xpert]) if W4SS is positive. To inform updated WHO guidelines, we aimed to assess the diagnostic accuracy of alternative screening tests and strategies for tuberculosis in this population. Methods: In this systematic review and individual participant data meta-analysis, we updated a search of PubMed (MEDLINE), Embase, the Cochrane Library, and conference abstracts for publications from Jan 1, 2011, to March 12, 2018, done in a previous systematic review to include the period up to Aug 2, 2019. We screened the reference lists of identified pieces and contacted experts in the field. We included prospective cross-sectional, observational studies and randomised trials among adult and adolescent (age ≥10 years) ambulatory people living with HIV, irrespective of signs and symptoms of tuberculosis. We extracted study-level data using a standardised data extraction form, and we requested individual participant data from study authors. We aimed to compare the W4SS with alternative screening tests and strategies and the WHO-recommended algorithm (ie, W4SS followed by Xpert) with Xpert for all in terms of diagnostic accuracy (sensitivity and specificity), overall and in key subgroups (eg, by antiretroviral therapy [ART] status). The reference standard was culture. This study is registered with PROSPERO, CRD42020155895. Findings: We identified 25 studies, and obtained data from 22 studies (including 15 666 participants; 4347 [27·7%] of 15 663 participants with data were on ART). W4SS sensitivity was 82% (95% CI 72–89) and specificity was 42% (29–57). C-reactive protein (≥10 mg/L) had similar sensitivity to (77% [61–88]), but higher specificity (74% [61–83]; n=3571) than, W4SS. Cough (lasting ≥2 weeks), haemoglobin (2), and lymphadenopathy had high specificities (80–90%) but low sensitivities (29–43%). The WHO-recommended algorithm had a sensitivity of 58% (50–66) and a specificity of 99% (98–100); Xpert for all had a sensitivity of 68% (57–76) and a specificity of 99% (98–99). In the one study that assessed both, the sensitivity of sputum Xpert Ultra was higher than sputum Xpert (73% [62–81] vs 57% [47–67]) and specificities were similar (98% [96–98] vs 99% [98–100]). Among outpatients on ART (4309 [99·1%] of 4347 people on ART), W4SS sensitivity was 53% (35–71) and specificity was 71% (51–85). In this population, a parallel strategy (two tests done at the same time) of W4SS with any chest x-ray abnormality had higher sensitivity (89% [70–97]) and lower specificity (33% [17–54]; n=2670) than W4SS alone; at a tuberculosis prevalence of 5%, this strategy would require 379 more rapid diagnostic tests per 1000 people living with HIV than W4SS but detect 18 more tuberculosis cases. Among outpatients not on ART (11 160 [71·8%] of 15 541 outpatients), W4SS sensitivity was 85% (76–91) and specificity was 37% (25–51). C-reactive protein (≥10 mg/L) alone had a similar sensitivity to (83% [79–86]), but higher specificity (67% [60–73]; n=3187) than, W4SS and a sequential strategy (both test positive) of W4SS then C-reactive protein (≥5 mg/L) had a similar sensitivity to (84% [75–90]), but higher specificity than (64% [57–71]; n=3187), W4SS alone; at 10% tuberculosis prevalence, these strategies would require 272 and 244 fewer rapid diagnostic tests per 1000 people living with HIV than W4SS but miss two and one more tuberculosis cases, respectively. Interpretation: C-reactive protein reduces the need for further rapid diagnostic tests without compromising sensitivity and has been included in the updated WHO tuberculosis screening guidelines. However, C-reactive protein data were scarce for outpatients on ART, necessitating future research regarding the utility of C-reactive protein in this group. Chest x-ray can be useful in outpatients on ART when combined with W4SS. The WHO-recommended algorithm has suboptimal sensitivity; Xpert for all offers slight sensitivity gains and would have major resource implications. Funding: World Health Organization.

UNSTRUCTURED The World Health Organization (WHO) recommends providing tuberculosis preventive treatment (TPT) to all persons living with HIV and to all household contacts of persons with bacteriologically confirmed pulmonary tuberculosis disease. Regrettably, the absence of a harmonized data collection and management approach to TPT indicators has contributed to programmatic challenges at local, national, and global levels. However, in April 2020, the WHO launched the Consolidated HIV Strategic Information Guidelines, with an updated set of priority indicators. These guidelines recommend that Ministries of Health collect, report, and use data on TPT completion in addition to TPT initiation. Both indicators are reflected in the WHO’s list of 15 core indicators for program management and are also required by the US President’s Emergency Plan for AIDS Relief’s Monitoring, Evaluation, and Reporting (MER) guidance. Although not perfectly harmonized, both frameworks now share essential indicator characteristics. Aligned indicators are necessary for robust strategic and operational planning, resource allocation, and data communication. “Collect once, use many times” is a best practice for strategic information management. Building harmonized and sustainable health systems will enable countries to successfully maintain essential HIV, tuberculosis, and other health services while combatting new health threats.

Latent tuberculosis infection (LTBI) is characterised by the presence of immune responses to previously acquired Mycobacterium tuberculosis infection without clinical evidence of active tuberculosis (TB). Here we report evidence-based guidelines from the World Health Organization for a public health approach to the management of LTBI in high risk individuals in countries with high or middle upper income and TB incidence of, Guidelines on LTBI for low TB incidence countries – essential element of the @WHO #EndTB strategy and TB elimination http://ow.ly/RW8xn

Purpose of review Guidelines developed by the WHO aim to provide recommendations to support best practice in health delivery, with a focus on low-income and middle-income countries. As part of the guideline development process, critical knowledge gaps are identified and one of the core functions of WHO guidelines is to set forth priorities for future research. A review of research priorities identified through the WHO guideline development has recently been promoted as one approach to building an overarching priority research agenda in a given area. This paper outlines priorities for HIV-associated TB research identified in WHO HIV and TB guidelines published since 2015. Recent findings Nine guidelines were reviewed and 29 priority research questions were identified. Research priorities were identified for prevention of HIV-associated TB (11 questions), screening of latent and active TB in people living with HIV (six questions), treatment of drug sensitive (four questions), and drug-resistant (two questions) TB, and treatment of HIV in people coinfected with TB (three questions). Summary Multiple approaches to defining priority research questions for health research exist. Research priorities that arise from the WHO guideline development process are limited to those areas for which guidelines are developed. One strength of this approach is that it takes as a starting point a desire to make actionable recommendations for policy makers. WHO is working to further refine the formulation of research questions within the guideline development process.

To develop and test a simple system for recording and reporting the diagnosis and treatment of latent tuberculosis infection and to compare the effects of passive and active tracing of child contacts on indicators of such infection.We revised Burkina Faso's latent tuberculosis infection register and quarterly tuberculosis reporting form. Subsequently, coverage of the routine screening of contacts, who were younger than five years, for active tuberculosis and the corresponding percentages of such contacts who, if eligible, initiated preventive therapy were measured, nationwide, between 1 April 2016 and 31 March 2017. In 2016, we evaluated indicators of latent tuberculosis infection in the Hauts-Bassins region before and after community health workers had begun the active tracing of contacts who were younger than five years.In Burkina Faso, during our study period, 3717 cases of pulmonary tuberculosis and 1166 corresponding contacts who were younger than five years were reported as the result of routine screening and passive contact tracing. The overall contact:index ratio was 0.31 and corresponding screening coverage was 82.0% (956/1166) and proportion of children starting on preventive treatment was 90.5% (852/941). Active tracing in Hauts-Bassins led to a substantially higher contact/index ratio (1.83) and screening coverage (99.3%; 145/146).The newly established recording and reporting system proved feasible and user-friendly and allowed measurement of global indicators of latent tuberculosis infection. Compared with active tracing, passive tracing led to much lower estimates of the numbers of child contacts.Élaborer et tester un système simple pour enregistrer et déclarer le diagnostic et le traitement des cas d'infection tuberculeuse latente et comparer les effets de la recherche passive et active des contacts enfants sur les indicateurs de cette infection.Nous avons passé en revue le registre des infections tuberculeuses latentes et le formulaire de rapport trimestriel des cas de tuberculose du Burkina Faso. Ensuite, nous avons mesuré, dans tout le pays, entre le 1Au Burkina Faso, au cours de la période étudiée, 3717 cas de tuberculose pulmonaire et 1166 contacts correspondants âgés de moins de cinq ans ont été déclarés dans le cadre du dépistage systématique et de la recherche passive des contacts. Le ratio total contacts/cas index était de 0,31 et le taux de couverture du dépistage correspondant s'élevait à 82,0% (956/1166), tandis que la proportion d'enfants ayant commencé un traitement préventif était de 90,5% (852/941). La recherche active dans les Hauts-Bassins a entraîné une hausse sensible du ratio total contacts/cas index (1,83) et du taux de couverture du dépistage (99,3%; 145/146).Le nouveau système d'enregistrement et de déclaration s'est avéré utilisable et convivial et a permis de mesurer les indicateurs globaux de l'infection tuberculeuse latente. En comparaison avec la recherche active, la recherche passive a généré des estimations beaucoup plus faibles du nombre de contacts enfants.Desarrollar y probar un sistema simple de registro y presentación de informes sobre el diagnóstico y el tratamiento de la infección tuberculosa latente y comparar los efectos del seguimiento pasivo y activo de los contactos infantiles con indicadores de dicha infección.Se revisó el registro de infección tuberculosa latente de Burkina Faso y el formulario trimestral de información sobre la tuberculosis. Posteriormente, se midió la cobertura de los exámenes de detección rutinarios a los contactos, menores de cinco años, para la tuberculosis activa y los porcentajes correspondientes de contactos que, de ser aptos, iniciaron la terapia preventiva a nivel nacional, entre el 1 de abril de 2016 y el 31 de marzo de 2017. En 2016, se evaluaron los indicadores de infección tuberculosa latente en la región de Hauts-Bassins antes y después de que los trabajadores comunitarios de la salud empezaran el seguimiento activo de los contactos menores de cinco años.En Burkina Faso, en nuestro periodo de estudio, se registraron 3717 casos de tuberculosis pulmonar y 1166 contactos correspondientes de menos de cinco años como resultado de un examen rutinario y un seguimiento del contacto pasivo. La tasa global de índice de contacto fue del 0,31 y la cobertura de detección correspondiente fue del 82,0% (956/1166), además, la proporción de niños que iniciaron el tratamiento preventivo fue del 90,5% (852/941). El seguimiento activo en Hauts-Bassins dio lugar a una relación de contacto/índice (1,83) y una cobertura de detección (99,3%; 145/146) sustancialmente más altas.El recién establecido sistema simple de registro y presentación de informes resultó factible y fácil de usar y permitió la medición de indicadores globales de la infección tuberculosa latente. En comparación con el seguimiento activo, el seguimiento pasivo dio lugar a estimaciones mucho más bajas de la cantidad de contactos secundarios.وضع واختبار نظام بسيط للتسجيل والإبلاغ عن حالات تشخيص وعلاج العدوى الكامنة بداء السل، ومقارنة آثار التتبع السلبي والنشط لحالات تعرض الأطفال إلى المرض بمؤشرات تلك العدوى.لقد راجعنا سجل الإصابة بداء السل الكامن في بوركينا فاصو، ونموذج البلاغات ربع السنوية للإصابة بداء السل. وبعد ذلك، تم قياس حجم تغطية الفحص الدوري لحالات الاتصال بالمرض بين الأطفال دون سن خمس سنوات للكشف عن حالات الإصابة النشطة بداء السل وما يقابلها من نسب الاتصال بالمرض بين الأطفال الذين شرعوا في تعاطي العلاج الوقائي إذا كانوا مؤهلين له، وذلك على مستوى البلاد في الفترة ما بين 1 أبريل/نيسان 2016 و31 مارس/آذار 2017. وفي عام 2016، قمنا بتقييم مؤشرات الإصابة بداء السل الكامن في منطقة أوت باسان قبل وبعد قيام الأخصائيين الصحيين المجتمعيين بالبدء في عمليات التتبع النشط لحالات الاتصال بالمرض بين الأطفال الذين تقل أعمارهم عن خمس سنوات.في بوركينا فاصو، تم الإبلاغ عن 3717 حالة للإصابة بداء السل الرئوي و1166 حالة مقابلة من الاتصال بالمرض بين الأطفال الأقل من خمس سنوات – كنتيجة للفحص الدوري وعمليات التتبع السلبي – وذلك خلال فترة الدراسة. وبلغت النسبة الإجمالية لحالات التعرض للمرض إلى مؤشر الإصابة 0.31، أما النسبة المقابلة لشمول خدمات الفحص فبلغت نسبتها 82.0‏% (بواقع ‏956/1166)، وبلغت نسبة الأطفال الذين بدأوا العلاج الوقائي 90.5‏% (852/941). وقادت عمليات التتبع النشط في منطقة أوت باسان إلى ارتفاع ملحوظ في نسبة حالات التعرض للمرض إلى مؤشر الإصابة (1.83)، أما نسبة شمول خدمات الفحص فبلغت (99.3‏%؛ 145/146).أثبت النظام الذي تم تأسيسه مؤخرًا لتسجيل حالات الإصابة وتقديم البلاغات عنها جدواه وسهولة استخدامه، وسمح بقياس المؤشرات العالمية لحالات العدوى الكامنة بداء السل. وبالمقارنة مع عمليات التتبع النشط، فقد قاد التتبع السلبي إلى تقديرات أقل كثيرًا لأعداد الأطفال الذين تعرضوا إلى الاتصال بالمرض.研发并测试一个简易系统，用于记录和报告潜在结核病感染的诊断与治疗，并对此类感染指标下针对儿童接触者分别进行被动追踪和主动追踪的效果进行比较。.我们修订了布基纳法索潜在结核病感染登记和季度结核病申报表。随后，在 2016 年 4 月 1 日至 2017 年 3 月 31 日之间，针对年龄不足 5 岁的活动性结核病患者进行常规性筛查并对此类符合条件的接触者开始实施预防性治疗，分别测量其在全国范围内的覆盖率和相应的百分比。2016 年，我们先评估了上盆地大区潜在结核病感染指标，之后，社区健康工作者开始积极追踪年龄不足 5 岁的儿童接触者。.在我们研究期间，经过常规性筛查和被动接触追踪，据报告称，布基纳法索有 3717 例结核病案例和 1166 位年龄不足 5 岁的相应接触者。总体接触指数比为 0.31，相应的筛查覆盖率为 82.0%（956/1166)，开始预防性治疗的儿童比例为 90.5%（852/941)。对上盆地大区的结核病积极追踪导致更高的接触指数比 （1.83） 和筛查覆盖率 （99.3%，145/146）。.新建立的记录报告系统被证明行之有效且用户友好，其可以评估潜伏结核病感染的全球指标。与积极追踪相比，消极追踪会造成对儿童接触者数量的低估。.Разработать и протестировать простую систему регистрации и отчетности для диагностики и лечения латентной туберкулезной инфекции и сравнить влияние пассивного и активного отслеживания детей, находившихся в контакте с инфицированным человеком, на показатели такой инфекции.Авторы изучили реестр лиц, больных латентным туберкулезом, в Буркина-Фасо и ежеквартальную форму отчетности о количестве больных туберкулезом. После этого по всей стране в период с 1 апреля 2016 года по 31 марта 2017 года была проведена оценка охвата регулярным скрининговым обследованием детей младше пяти лет, находившихся в контакте с инфицированным человеком, на предмет выявления активного туберкулеза и соответствующей доли таких детей, для которых при необходимости была назначена профилактическая терапия. В 2016 году мы оценили показатели латентной туберкулезной инфекции в области Верхних Бассейнов до и после того, как работники здравоохранения начали активное отслеживание детей младше пяти лет, находившихся в контакте с инфицированным человеком.В Буркина-Фасо в течение периода исследования авторов в результате регулярного скрининга и пассивного отслеживания контактов было зарегистрировано 3717 случаев туберкулеза легких и 1166 соответствующих детей младше пяти лет, находившихся в контакте с инфицированным человеком. Общее соотношение «контакт/показатель» составило 0,31, соответствующий охват скрининговым обследованием — 82,0% (956/1166), а доля детей, для которых было назначено профилактическое лечение, — 90,5% (852/941). Активное отслеживание в области Верхних Бассейнов привело к значительно более высокому соотношению «контакт/показатель» (1,83) и охвату скрининговым обследованием (99,3%, 145/146).Недавно созданная система регистрации и отчетности оказалась выполнимой и удобной для пользователей и позволила измерить глобальные показатели латентной туберкулезной инфекции. При сравнении с активным отслеживанием пассивное отслеживание привело к значительно более низким показателям количества детей, находившихся в контакте с инфицированным человеком.

Every year, 24 March is commemorated the world over for the announcement of the discovery of the cause of tuberculosis (TB) by Robert Koch in 1882. Koch’s discovery of Mycobacterium tuberculosis paved the way for diagnosing and curing TB, yet, more than 130 years later, this ancient disease still takes a heavy toll on mankind—TB remains the leading cause of death from a single infectious agent and ranks ninth among the top 10 causes of death globally.1 WHO’s 2017 Global TB Report estimated 10.4 million incident cases of TB (of which 1 million were attributable to HIV), and 600 000 cases of multidrug-resistant (MDR) TB and rifampicin-resistant TB.1 TB also remains the leading killer of people with HIV, with 374 000 deaths in 2016. MDR TB represents a growing threat to global health and national security, claiming nearly 240 000 lives per year and representing a major component of estimated annual deaths due to antimicrobial resistance.2 Although 53 million lives have been saved through global efforts since 2000, there is no evidence of acceleration in the decline in TB incidence, mortality and suffering. Currently, more than 40% of the estimated global TB burden goes undetected or unreported. Four out of five persons with MDR TB do not receive appropriate treatment. More than half of all people with TB and HIV are not reported to receive care and almost half of reported patients with TB are managed without an HIV test result.1 Inadequate patient-centred care and multiple hurdles faced by people with TB, including catastrophic …

Considerable progress has been made in the provision of life-saving antiretroviral therapy (ART) for persons with human immunodeficiency virus (HIV) infection worldwide, resulting in an overall decrease in HIV incidence and acquired immunodeficiency syndrome (AIDS)-related mortality. In the strategic scale-up of HIV care and treatment programs, persons with HIV and tuberculosis (TB) are a priority population for receiving ART. TB is the leading cause of death among persons living with HIV in sub-Saharan Africa and remains a potential risk to the estimated 35 million persons living with HIV globally. Of the 9 million new cases of TB disease globally in 2013, an estimated 1.1 million (13%) were among persons living with HIV; of the 1.5 million deaths attributed to TB in 2013, a total of 360,000 (24%) were among persons living with HIV. ART reduces the incidence of HIV-associated TB disease, and early initiation of ART after the start of TB treatment reduces progression of HIV infection and death among HIV-positive TB patients. To assess the progress in scaling up ART provision among HIV-positive TB patients in 19 countries in sub-Saharan Africa with high TB and HIV burdens, TB and HIV data collected by the World Health Organization (WHO) were reviewed. The results found that the percentage of HIV-positive TB patients receiving ART increased from 37% in 2010 to 69% in 2013. However, many TB cases among persons who are HIV-positive go unreported, and only 38% of the estimated number of HIV-positive new TB patients received ART in 2013. Although progress has been made, the combination of TB and HIV continues to pose a threat to global health, particularly in sub-Saharan Africa.

People who use and inject illicit drugs are at high risk of contracting tuberculosis, whether or not they are infected with the human immunodeficiency virus (HIV). Studies conducted before and after the emergence of HIV infection show that, when compared with the general population, people who use illicit drugs have a higher risk not just of getting tuberculosis infection, but also of developing active disease.1,2 Similarly, outbreaks of drug-susceptible and multidrug resistant (MDR) tuberculosis are common in this group.1 Although the higher risk of tuberculosis observed in people who inject illicit drugs is usually the result of associated HIV infection, in people who use illicit drugs without injecting this higher risk is primarily attributable to the sharing of drug equipment, such as marijuana water pipes, and to living in cramped conditions or in dwellings with poor ventilation.1 Co-infection with the hepatitis B and hepatitis C viruses is also common among patients who inject illicit drugs, particularly among those who are also co-infected with the tuberculosis bacillus and HIV.2 Although most reports on hepatitis among people who use illicit drugs have come from high-income settings, some alarming reports have also been produced about middle- and low-income settings. For example, in a study among people using illicit drugs in Chennai, India, hepatitis B and C showed a prevalence of 11.9% and 94.1%, respectively.3 Illicit drug use is often associated with alcoholism, which also increases the risk of becoming infected with the tuberculosis bacillus and of developing active tuberculosis. It also complicates tuberculosis diagnosis and treatment. Furthermore, drug use is criminalized in many settings. In a study by Hayashi et al., up to 80% of the study subjects who injected illicit drugs had been incarcerated at least once.4 Prisons are well established breeding sites for tuberculosis and HIV infection, especially in settings where no preventive measures are in place and where illicit drug use and drug equipment sharing are common among prisoners.2 As a result, the risk of becoming infected with the tuberculosis bacillus and the risk of developing active tuberculosis are 26 and 23 times higher, respectively, among prisoners than among members of the general population.2 These factors, combined with an increased risk of tuberculosis-related morbidity and mortality among people using illicit drugs, complicate the clinical management of tuberculosis patients and the administration of tuberculosis programmes. Diagnosing tuberculosis is more complicated in a high-risk population, such as people who use illicit drugs. The recent introduction of a rapid diagnostic test (Xpert MTB/RIF) offers an ideal opportunity to improve diagnosis in such groups because it detects tuberculosis twice as effectively as smear microscopy without any significant difference in performance as a function of HIV status.2 The World Health Organization recommends it as the initial diagnostic test in individuals suspected of having MDR-tuberculosis or tuberculosis associated with HIV infection. The test may therefore expedite the diagnosis of tuberculosis among people who use illicit drugs, since MDR-tuberculosis and HIV infection are common among them. At the same time, little evidence has been generated in terms of the clinical management of people who use illicit drugs and who also have either drug-susceptible or drug-resistant tuberculosis, HIV infection or hepatitis. The management of these co-morbid conditions requires sound clinical judgment; treatment should be guided by the patient’s clinical condition and by the possibility of drug side-effects and interactions. Additive adverse effects, overall pill burden and adherence to treatment require special attention as well. The prevention, diagnosis and treatment of tuberculosis among people who use illicit drugs have been neglected and require immediate attention. Open dialogue on policy in this area should be encouraged, and a coordinated programme response from stakeholders working in prisons and in harm reduction, HIV infection, hepatitis and tuberculosis services should be sought. People who use illicit drugs and prisoners should be provided with evidence-based, integrated tuberculosis, HIV, hepatitis and harm reduction services that fully respect basic human rights.