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Background: Tuberculosis remains the leading cause of death by an infectious disease among people living with HIV (PLHIV). TB Preventive Treatment (TPT) is a cost-effective intervention known to reduce morbidity and mortality. We used data from ZIMPHIA 2020 to assess TPT uptake and factors associated with its use., Methodology: ZIMPHIA a cross-sectional household survey, estimated HIV treatment outcomes among PLHIV aged ≥15 years. Randomly selected participants provided demographic and clinical information. We applied multivariable logistic regression models using survey weights. Variances were estimated via the Jackknife series to determine factors associated with TPT uptake., Results: The sample of 2419 PLHIV ≥15 years had 65% females, 44% had no primary education, and 29% lived in urban centers. Overall, 38% had ever taken TPT, including 15% currently taking TPT. Controlling for other variables, those screened for TB at last HIV-related visit, those who visited a TB clinic in the previous 12 months, and those who had HIV viral load suppression were more likely to take TPT., Conclusion: The findings show suboptimal TPT coverage among PLHIV. There is a need for targeted interventions and policies to address the barriers to TPT uptake, to reduce TB morbidity and mortality among PLHIV., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Authors affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

Setting: Peri-urban health facilities providing HIV and TB care in Zambia., Objective: To evaluate 1) the impact of Xpert ® MTB/RIF on time-to-diagnosis, treatment initiation, and outcomes among adult people living with HIV (PLHIV) on antiretroviral therapy (ART); and 2) the diagnostic performance of Xpert and Determine™ TB-LAM Ag assays., Design: Quasi-experimental study design with the first cohort evaluated per standard-of-care (SOC; first sputum tested using smear microscopy) and the second cohort per an algorithm using Xpert as initial test (intervention phase; IP). Xpert testing was provided onsite in Chongwe District, while samples were transported 5-10 km in Kafue District. TB was confirmed using mycobacterial culture., Results: Among 1350 PLHIV enrolled, 156 (15.4%) had confirmed TB. Time from TB evaluation to diagnosis ( P = 0.018), and from evaluation to treatment initiation ( P = 0.03) was significantly shorter for IP than for SOC. There was no difference in all-cause mortality (7.0% vs. 8.6%). TB-LAM Ag showed higher sensitivity with lower CD4 cell count: 81.8% at CD4 < 50 cells/mm 3 vs. 31.7% overall., Conclusion: Xpert improved time to diagnosis and treatment initiation, but there was no difference in all-cause mortality. High sensitivity of Determine TB-LAM Ag at lower CD4 count supports increased use in settings providing care to PLHIV, particularly with advanced HIV disease., Competing Interests: Conflicts of interest: none declared., (© 2020 The Union.)

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.

Context: One of the biggest hurdles to the rapid scale-up of antiretroviral therapy in the developing world was the price of antiretroviral drugs (ARVs). Modification of an existing US Food and Drug Administration (FDA) process to expedite review and approval of generic ARVs quickly resulted in a large number of FDA-tentatively approved ARVs available for use by the US President's Emergency Plan for AIDS Relief (PEPFAR)., Objective: To evaluate the uptake of generic ARVs among PEPFAR-supported programs in Guyana, Haiti, Vietnam, and 13 countries in Africa, and changes over time in ARV use and costs., Design, Setting, and Participants: An annual survey from 2005 to 2008 of ARVs purchased in 16 countries by PEPFAR implementing and procurement partners (organizations using PEPFAR funding to purchase ARVs)., Main Outcome Measures: Drug expenditures, ARV types and volumes (assessed per pack, a 1-month supply), proportion of generic procurement across years and countries, and cost savings from generic procurement., Results: ARV expenditures increased from $116.8 million (2005) to $202.2 million (2008); and procurement increased from 6.2 million to 22.1 million monthly packs. The proportion spent on generic ARVs increased from 9.17% (95% confidence interval [CI], 9.17%-9.18%) in 2005 to 76.41% (95% CI, 76.41%-76.42%) in 2008 (P < .001), and the proportion of generic packs procured increased from 14.8% (95% CI, 14.79%-14.84%) in 2005 to 89.33% (95% CI, 89.32%-89.34%) in 2008 (P < .001). In 2008, there were 8 PEPFAR programs that procured at least 90.0% of ARV packs in generic form; South Africa had the lowest generic procurement (24.7%; 95% CI, 24.6%-24.8%). Procurement of generic fixed-dose combinations increased from 33.3% (95% CI, 33.24%-33.43%) in 2005 to 42.73% (95% CI, 42.71%-42.75%) in 2008. Estimated yearly savings generated through generic ARV use were $8,108,444 in 2005, $24,940,014 in 2006, $75,645,816 in 2007, and $214,648,982 in 2008, a total estimated savings of $323,343,256., Conclusion: Among PEPFAR-supported programs in 16 countries, availability of generic ARVs was associated with increased ARV procurement and substantial estimated cost savings.

The World Health Organization (WHO) released the Stop TB Strategy in 2006, along with a revised version of the tuberculosis (TB) recording and reporting forms and register. These publications illustrate the need for an enhanced TB surveillance system that will include such key elements as rapid assessment of the quality of DOTS services; integration and response to the human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) epidemic; TB control challenges, such as increased smear-negative and extra-pulmonary TB and multidrug-resistant TB (MDR-TB); increased engagement of all care providers, such as private health care services and the community; and promotion of research to support program improvement. Electronic surveillance systems utilize computer technology to facilitate the capture, transfer and reporting of the WHO-recommended TB data elements. Electronic surveillance offers several potential advantages over the traditional paper-based systems used in many low-resource settings, such as improved data quality and completeness, more feasible links to other health care programs, quality-enhanced data entry and analysis features and increased data security. These advantages must, however, be weighed against the requirements and costs of electronic surveillance, including implementation and support of a quality paper-based surveillance system and the additional costs associated with infrastructure, training and human resources for the implementation and continuing support of an electronic system. Using examples from three different electronic TB surveillance systems that are being implemented in various resource-limited settings, this article demonstrates the feasibility, requirements and value of such systems to support the WHO-recommended enhancement of TB surveillance.

Setting: Tuberculosis (TB) rates in southern Africa have increased dramatically in recent years. Provision of accurate data for surveillance, program management, and supervision is increasingly essential., Objective: To develop software that would provide more efficient collection, compilation, and analysis of TB data on an ongoing basis., Design: The 'Electronic TB Register' is a user-friendly, Epi-Info based software program based on the WHO/IUATLD format of recording and reporting. Individual records from the TB registry are entered in a program that provides interactive support. The software provides several patient management and supervision functions, such as lists of defaulters. Finally, it generates standard quarterly and annual reports on case-finding, sputum conversion, and cohort analysis, and provides graphs of trends and maps of TB indicators., Results: The 'Electronic TB Register' software has been successfully implemented in five pilot projects in southern Africa. User acceptance has been high and quality of data has improved, although timeliness remains unchanged. Factors critical for success include a functioning, paper-based system, involvement of staff from the TB program, health information systems, and health facilities, ongoing training, and backup support., Conclusions: The 'Electronic TB Register' is a potentially powerful tool for surveillance, management, and supervision for countries with well-functioning paper-based recording and reporting systems.

Background: An ongoing restriction fragment length polymorphism study of Mycobacterium tuberculosis isolates from tuberculosis cases showed an identical 12-band IS6110 pattern unique to 3 unrelated patients (Patients A-C) diagnosed as having tuberculosis within a 9-month period., Methods: In an attempt to identify epidemiologic links between the 3 patients, we performed site visits to the retail business work site of patient A and conducted detailed interviews with all 3 patients and their contacts., Results: Patient B had visited patient A's work site 3 times during patient A's infectious period, spending no more than 15 minutes each time. Patient C visited patient A's work site on 6 to 10 occasions during this period for no more than 45 minutes at any one time. There were no other epidemiologic links between these 3 cases other than the contact at the store. Contact investigation identified 4 tuberculin skin test conversions among 8 (50%) of patient A's coworkers, 6 positive tests among 15 household contacts (40%), and 8 positive tests among 16 identified customers who were casual contacts (50%). Patient B and patient C were most likely infected by patient A during one of their brief visits to patient A's work site., Conclusions: These data demonstrate that some tuberculosis is spread through casual contact not normally pursued in traditional contact investigations and that, in certain situations, M tuberculosis can be transmitted despite minimal duration of exposure. In addition, this outbreak emphasizes the importance of DNA fingerprinting data for identifying unusual transmission in unexpected settings.

Objective: To determine the rate of tuberculosis relapse among HIV-seropositive and -seronegative persons treated for active tuberculosis with short-course (6-month) therapy., Design: Consecutive cohort study., Setting: City of Baltimore tuberculosis clinic., Patients: Tuberculosis patients treated between 1 January 1993 and 31 December 1996., Intervention: Patients received 2 months of isoniazid, rifampin, pyrazinamide and ethambutol followed by 4 months of isoniazid and rifampin., Main Outcome Measure: Passive follow-up for tuberculosis relapse was performed through September 30, 1998., Results: There were 423 cases of tuberculosis during the study period; 280 patients completed a 6-month course of therapy. Therapy was directly-observed for 94% of patients. Of those who completed therapy, 47 (17%) were HIV-seropositive, 127 (45%) were HIV-seronegative, and 106 (38%) had unknown HIV status. HIV-infected patients required more time to complete therapy (median 225 versus 205 days; P = 0.04) but converted sputum culture to negative within the same time period (median 77 versus 72 days; P = 0.43) as HIV-seronegative or unknown patients. Relapse occurred in three out of 47 (6.4%) HIV-infected patients compared to seven out of 127 (5.5%) HIV-seronegative patients (P = 1.0). Relapse rates also did not differ when HIV-seropositive patients were compared with HIV-seronegative and patients with unknown HIV status (6.4% versus 3.0%; P = 0.38). Of the 10 patients with tuberculosis relapse, restriction fragment length polymorphism data were available for five; all five relapse isolates matched the initial isolate., Conclusions: These results support current recommendations to treat tuberculosis in HIV-infected patients with short-course (6-month) therapy.