Notification of relapse and other previously treated tuberculosis in the 52 health districts of South Africa.

OBJECTIVE: To investigate the extent to which relapse and other previously treated tuberculosis (TB) contribute to the notified TB burden in South Africa.DESIGN: We conducted an ecological analysis at the level of the 52 South African health districts using national electronic TB register data. We included all bacteriologically confirmed TB cases treated for presumed drug-susceptible TB in 2011. Treatment history information was based on recorded patient categories (new vs. retreatment).RESULTS: Relapse and other previously treated TB cases constituted between 7.6% and 40% (median 17%, interquartile range 12-22) of all bacteriologically confirmed TB cases in the 52 South African districts. Multivariable analysis suggested that districts with higher proportions of previously treated TB cases had higher TB case notification rates (P < 0.001), lower estimates of antenatal human immunodeficiency virus (HIV) prevalence in the district population (P < 0.001) as well as lower HIV co-infection rates (P < 0.001) among new TB cases.CONCLUSION: Relapse and other previously treated TB cases contributed substantially to the notified TB burden in several South African health districts, particularly those with high case notification rates and lower antenatal HIV prevalence. Additional efforts to prevent TB among previously treated people, such as strengthening treatment monitoring and/or secondary preventive therapy, should be considered.

Renal dysfunction by baseline CD4 cell count in a cohort of adults starting antiretroviral treatment regardless of CD4 count in the HIV Prevention Trials Network 071 [HPTN 071; Population Effect of Antiretroviral Therapy to Reduce HIV Transmission (PopART)] study in South Africa.

OBJECTIVES: Renal dysfunction is a significant cause of morbidity and mortality among HIV-positive individuals. This study evaluated renal dysfunction in a cohort of adults who started antiretroviral treatment (ART) regardless of CD4 count at three Department of Health (DOH) clinics included in the HIV Prevention Trials Network 071 (HPTN 071) Population Effect of Antiretroviral Therapy to Reduce HIV Transmission (PopART) trial. METHODS: A retrospective cohort analysis of routine data for HIV-positive individuals starting ART between January 2014 and November 2015 was completed. Incident renal dysfunction was defined as an estimated glomerular filtration rate (eEGFR) < 60 mL/min after ART initiation among individuals with a baseline (pre-ART) eGFR ≥ 60 mL/min. RESULTS: Overall, 2423 individuals, with a median baseline CD4 count of 328 cells/µL [interquartile range (IQR) 195-468 cells/µL], were included in the analysis. Forty-seven individuals had a baseline eGFR < 60 mL/min. Among 1634 nonpregnant individuals started on a tenofovir-containing ART regimen and with a baseline eGFR ≥ 60 mL/min, 27 developed an eGFR < 60 mL/min on ART. Regression analysis showed lower odds of baseline eGFR < 60 mL/min at baseline CD4 counts of > 500 cells/µL [adjusted odds ratio (aOR) 0.29; 95% confidence interval (CI) 0.11-0.80], 351-500 cells/µL (aOR 0.22; 95% CI 0.08-0.59) and 201-350 (aOR 0.48; 95% CI: 0.24-0.97) compared with baseline CD4 counts < 200 cells/µL. CONCLUSIONS: This study showed low rates of renal dysfunction at baseline and on ART, with lower rates of baseline renal dysfunction among individuals with baseline CD4 counts > 200 cells/µL. Strategies that use baseline characteristics, such as age, to identify individuals at high risk of renal dysfunction on ART for enhanced eGFR monitoring may be effective and should be the subject of future research.

Improving rifampicin-resistant tuberculosis diagnosis using Xpert® MTB/RIF: modelling interventions and costs.

SETTING: Cape Town, South Africa. OBJECTIVE: To model the diagnosis of rifampicin-resistant tuberculosis (RR-TB) and laboratory costs of smear/culture and Xpert-based algorithms and the effect of varying adherence and human immunodeficiency virus (HIV) testing in the Xpert-based algorithm. METHODS: We used a validated operational model (100 000 population) and published laboratory cost data. We estimated the number and cost of RR-TB cases identified using the smear/culture- and Xpert-based algorithms. We modelled varying adherence and different levels of known HIV status against the Xpert-based algorithm. RESULTS: The number of RR-TB cases identified increased from 603 with smear/culture to 1178 with the Xpert-based algorithm (100% adherence; 60% knew their HIV status). The overall laboratory cost increased from US$1 073 858 to US$2 430 050 and the cost per RR-TB case identified increased from US$1781 to US$2063 in the respective algorithms. When adherence to the Xpert-based algorithm was increased from 50% to 100% (60% knew their HIV status), the number of RR-TB cases identified increased from 721 to 1178. CONCLUSION: The Xpert-based algorithm is efficient in identifying RR-TB, as the increase in costs is offset by the increase in the number of cases identified. Adherence to the Xpert-based algorithm is important to ensure that all presumptive TB cases receive the benefit of simultaneous TB and RR-TB testing.

Five-year follow-up of participants diagnosed with chronic airflow obstruction in a South African Burden of Obstructive Lung Disease (BOLD) survey.

BACKGROUND: A community-based prevalence survey performed in two suburbs in Cape Town, South Africa (SA), in 2005, using the international Burden of Obstructive Lung Disease (BOLD) method, confirmed a prevalence of chronic airflow obstruction (CAO) in 23.1% of adults aged >40 years. OBJECTIVES: To study the clinical course and prognosis over 5 years of patients with CAO identified in the 2005 survey. METHODS: Patients with CAO in 2005 were invited to participate. Standard BOLD and modified questionnaires were completed. Spirometry was performed using spirometers of the same make as in 2005. RESULTS: Of 196 eligible participants from BOLD 2005, 45 (23.0%) had died, 8 from respiratory causes, 10 from cardiovascular causes and 6 from other known causes, while in 21 cases the cause of death was not known. On multivariate analysis, only age and Global initiative for Obstructive Lung Disease (GOLD) stage 4 disease at baseline were significantly associated with death. Of the 151 survivors, 11 (5.6% of the original cohort) were unavailable and 33 (16.8%) declined or had medical exclusions. One hundred and seven survivors were enrolled in the follow-up study (54.6%, median age 63.1 years, 45.8% males). Post-bronchodilator spirometry performed in 106 participants failed to confirm CAO, defined as a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of <0.7, in 16 participants (15.1%), but CAO was present in 90. The median decline in FEV1 was 28.9 mL/year (interquartile range -54.8 - 0.0) and was similar between GOLD stages. The median total decline in FVC was 75 mL, and was significantly greater in GOLD stage 1 (-350 mL) than in stages 2 or 3 (-80  mL and +140 mL, respectively; p<0.01). Fifty-eight participants with CAO in 2005 (64.4%) remained in the same GOLD stage, while 21 (23.3%) deteriorated and 11 (12.2%) improved by ≥1 stage. Only one-third were receiving any treatment for chronic obstructive pulmonary disease (COPD). CONCLUSIONS: The prevalence, morbidity and mortality of CAO and COPD in SA are high and the level of appropriate treatment is very low, pointing to underdiagnosis and inadequate provision of and access to effective treatments and preventive strategies for this priority chronic non-communicable disease.

High laboratory cost predicted per tuberculosis case diagnosed with increased case finding without a triage strategy.

SETTING: Cape Town, South Africa. OBJECTIVE: To model the effects of increased case finding and triage strategies on laboratory costs per tuberculosis (TB) case diagnosed. METHODS: We used a validated operational model and published laboratory cost data. We modelled the effect of varying the proportion with TB among presumptive cases and Xpert cartridge price reductions on cost per TB case and per additional TB case diagnosed in the Xpert-based vs. smear/culture-based algorithms. RESULTS: In our current scenario (18.3% with TB among presumptive cases), the proportion of cases diagnosed increased by 8.7% (16.7% vs. 15.0%), and the cost per case diagnosed increased by 142% (US$121 vs. US$50). The cost per additional case diagnosed was US$986. This would increase to US$1619 if the proportion with TB among presumptive cases was 10.6%. At 25.9-30.8% of TB prevalence among presumptive cases and a 50% reduction in Xpert cartridge price, the cost per TB case diagnosed would range from US$50 to US$59 (comparable to the US$48.77 found in routine practice with smear/culture). CONCLUSION: The operational model illustrates the effect of increased case finding on laboratory costs per TB case diagnosed. Unless triage strategies are identified, the approach will not be sustainable, even if Xpert cartridge prices are reduced.

Operational modelling: the mechanisms influencing TB diagnostic yield in an Xpert® MTB/RIF-based algorithm.

SETTING: Cape Town, South Africa. OBJECTIVE: To compare the diagnostic yield for smear/culture and Xpert® MTB/RIF algorithms and to investigate the mechanisms influencing tuberculosis (TB) yield. METHOD: We developed and validated an operational model of the TB diagnostic process, first with the smear/culture algorithm and then with the Xpert algorithm. We modelled scenarios by varying TB prevalence, adherence to diagnostic algorithms and human immunodeficiency virus (HIV) status. This enabled direct comparisons of diagnostic yield in the two algorithms to be made. RESULTS: Routine data showed that diagnostic yield had decreased over the period of the Xpert algorithm roll-out compared to the yield when the smear/culture algorithm was in place. However, modelling yield under identical conditions indicated a 13.3% increase in diagnostic yield from the Xpert algorithm compared to smear/culture. The model demonstrated that the extensive use of culture in the smear/culture algorithm and the decline in TB prevalence are the main factors contributing to not finding an increase in diagnostic yield in the routine data. CONCLUSION: We demonstrate the benefits of an operational model to determine the effect of scale-up of a new diagnostic algorithm, and recommend that policy makers use operational modelling to make appropriate decisions before new diagnostic algorithms are scaled up.

Symptom screening rules to identify active pulmonary tuberculosis: Findings from the Zambian South African Tuberculosis and HIV/AIDS Reduction (ZAMSTAR) trial prevalence surveys.

BACKGROUND: High tuberculosis (TB) burden countries should consider systematic screening among adults in the general population. We identified symptom screening rules to be used in addition to cough ≥2 weeks, in a context where X-ray screening is not feasible, aiming to increase the sensitivity of screening while achieving a specificity of ≥85%. METHODS: We used 2010 Zambia South Africa Tuberculosis and HIV/AIDS Reduction (ZAMSTAR) survey data: a South African (SA) training dataset, a SA testing dataset for internal validation and a Zambian dataset for external validation. Regression analyses investigated relationships between symptoms or combinations of symptoms and active disease. Sensitivity and specificity were calculated for candidate rules. RESULTS: Among all participants, the sensitivity of using only cough ≥2 weeks as a screening rule was less than 25% in both SA and Zambia. The addition of any three of six TB symptoms (cough <2 weeks, night sweats, weight loss, fever, chest pain, shortness of breath), or 2 or more of cough <2 weeks, night sweats, and weight loss, increased the sensitivity to ~38%, while reducing specificity from ~95% to ~85% in SA and ~97% to ~92% in Zambia. Among HIV-negative adults, findings were similar in SA, whereas in Zambia the increase in sensitivity was relatively small (15% to 22%). CONCLUSION: High TB burden countries should investigate cost-effective strategies for systematic screening: one such strategy could be to use our rule in addition to cough ≥2 weeks.

What drives 'first-time testers' to test for HIV at community-based HIV testing services?

Drivers of and barriers to testing are not well understood for those who have never been tested previously and now self-initiate at a community-based human immuno-deficiency virus (HIV) testing service (CB-HTS). This descriptive study enrolled 229 first-time testers. Participants completed an electronic questionnaire. The majority reported fear and (non) accessibility of HTS as barriers to testing (40% and 24%, respectively). Wanting 'to know my status' and the immediate opportunity to test were reported as drivers of testing (41% and 35%, respectively). Addressing fear of testing and providing an easily accessible opportunity to test may go some way to encouraging those previously untested individuals to test.

Les facteurs qui amènent à réaliser un test et ceux qui les entravent ne sont pas bien compris pour ceux qui n'ont jamais été testés auparavant et en prennent l'initiative dans un service de test pour le virus de l'immunodéficience humaine (VIH) basé en communauté (CB-HTS). Cette étude descriptive a enrôlé 229 patients testés pour la première fois. Les participants ont rempli un questionnaire électronique. La majorité a déclaré que la crainte et la (non) accessibilité du HTS étaient des entraves au test (40% et 24%, respectivement). Vouloir « connaître son statut ¼ et l'opportunité de faire le test immédiatement ont été les moteurs de la réalisation du test (41% et 35%, respectivement). Répondre aux craintes individuelles de se faire tester et offrir une opportunité facilement accessible de le réaliser contribueraient à amener au test ceux qui ne l'ont jamais fait.

No se conocen plenamente los impulsores y los obstáculos a la práctica de las pruebas diagnósticas de la infección por el virus de la inmunodeficiencia humana (VIH), en las personas que nunca han recibido la prueba y que ahora, por iniciativa propia, acuden a los servicios comunitarios que la ofrecen. En el presente estudio descriptivo se incorporaron 229 personas que recibían la prueba diagnóstica por primera vez. Los participantes completaron un cuestionario en formato electrónico. La mayoría refirió como obstáculos a la práctica de la prueba el temor (40%) y la (falta de) accesibilidad de los servicios que la ofrecen (24%). Los factores referidos como impulsores de la búsqueda de la prueba fueron el hecho de 'querer conocer su estado' (41%) y la oportunidad inmediata de hacerla (35%). Abordar el temor de las personas y ofrecer una oportunidad fácilmente accesible de realizar la prueba diagnóstica del VIH puede contribuir a que las personas que nunca han realizado la prueba, la acepten.

Access to human immunodeficiency virus testing services in Cape Town, South Africa: a user perspective.

Objective: To compare the availability, affordability and acceptability of two non-governmental organisation (NGO) led human immunodeficiency virus (HIV) testing service (HTS) modalities (mobile and stand-alone) with HTS at a public primary health care facility. Methods: Adult participants who self-referred for HIV testing were enrolled as they exited the HTS modalities. Data collection using an electronic questionnaire took place between November 2014 and February 2015. Logistic regression analysis was used to assess differences in the participants' demographic characteristics and the availability, affordability and acceptability of HTS between modalities. Results: There were 130 participants included in the study. Irrespective of modality, most participants walked to the service provider, had a travel time of <30 min and reported no costs. Participants were less likely to report waiting times of ⩾30 min compared to <15 min at the mobile modality compared to the public facility (aOR < 0.001, 95%CI < 0.001-0.03). Conclusion: Irrespective of modality, HIV testing services were available and affordable in our study. Waiting times were significantly higher at the public facility compared to the NGO modalities. As South Africa moves toward achieving the first UNAIDS target, it is essential not only to make HTS available and affordable, but also to ensure that these services are acceptable, especially to those who have never been tested before.

Objectif : Comparer la disponibilité, l'accessibilité et l'acceptabilité de deux modalités de services de test du virus de l'immunodéficience humaine (VIH) (HTS) : modalité mobile réalisée par des organisations non gouvernementales (ONG) et modalité autonome réalisée par une structure de soins de santé primaires.Méthodes : Les participants adultes qui se sont présentés pour un test VIH ont été enrôlés lors de leur sortie des modalités de HTS. Le recueil de données, basé sur un questionnaire électronique, a eu lieu entre novembre 2014 et février 2015. Une analyse de régression logistique a été utilisée afin d'évaluer les différences des caractéristiques démographiques des participants et de la disponibilité, de l'accessibilité et de l'acceptabilité du HTS selon les modalités.Résultats : Des 130 participants qui ont été inclus dans l'étude, quelle que soit la modalité, la majorité s'est rendue à pied chez le prestataire de soins, marchant pendant <30 min, et n'a subi aucun coût. Les participants des structures mobiles ont été moins susceptibles que ceux de la structure publique de rapporter un temps de trajet ⩾ 30 min comparés à <15 min (ORa < 0,001 ; IC95% < 0,001­0,03).Conclusion : Les services de test VIH, quelle que soit la modalité, ont été disponibles et abordables dans notre étude. Les durées d'attente ont été significativement plus élevées dans la structure publique comparée aux modalités des ONG. Comme l'Afrique du Sud évolue vers l'atteinte de la première cible de l'ONUSIDA, il est essential non seulement de rendre le HST disponible et abordable, mais également de s'assurer que ces services sont acceptables, surtout à ceux qui n'ont jamais eu de test auparavant.

Objetivo: Comparar la disponibilidad, la asequibilidad y la aceptabilidad de dos modalidades de servicios de pruebas diagnósticas del virus de inmunodeficiencia humana (VIH) (HTS móvil y fijo independiente) propuestas por organizaciones no gubernamentales (ONG) y los servicios diagnósticos propuestos en un establecimiento público de atención primaria de salud.Métodos: Los adultos que acudían de manera espontánea en busca de pruebas diagnósticas se incluyeron en el estudio a la salida de los HTS. Se recogieron datos por conducto de un cuestionario electrónico de noviembre 2014 hasta febrero 2015. Mediante análisis de regresión logística se evaluaron las diferencias en las características demográficas de los participantes y la disponibilidad, la asequibilidad y la aceptabilidad de los HTS según las diferentes modalidades.Resultados: Participaron en el estudio 130 personas. Con independencia de la modalidad, la mayoría de los participantes caminó hasta el punto de prestación de servicios, su tiempo de desplazamiento fue <30 min y refirió no haber incurrido en ningún gasto. Fue menos probable que los usuarios de los servicios móviles refiriesen un tiempo de espera ⩾ 30 min en lugar de <15 min, al compararlos con los usuarios del establecimiento público (P < 0,001; IC95% < 0,001­0,03).Conclusión: El presente estudio reveló que los servicios de pruebas diagnósticas del VIH, sea cual fuere su modalidad, estaban disponibles y eran asequibles. Los tiempos de espera fueron significativamente más prolongados en el establecimiento público, en comparación con la espera en las modalidades de las ONG. A medida que Suráfrica progresa hacia el cumplimiento de la primera meta del Programa Conjunto de las Naciones Unidas sobre el VIH/SIDA, es primordial, no solo que los HTS estén disponibles y sean asequibles, sino que se garantice su aceptabilidad, sobre todo por parte las personas que nunca han recibido la prueba.

Comparing laboratory costs of smear/culture and Xpert® MTB/RIF-based tuberculosis diagnostic algorithms.

SETTING: Cape Town, South Africa, where Xpert® MTB/RIF was introduced as a screening test for all presumptive tuberculosis (TB) cases. OBJECTIVE: To compare laboratory costs of smear/culture- and Xpert-based tuberculosis (TB) diagnostic algorithms in routine operational conditions. METHODS: Economic costing was undertaken from a laboratory perspective, using an ingredients-based costing approach. Cost allocation was based on reviews of standard operating procedures and laboratory records, timing of test procedures, measurement of laboratory areas and manager interviews. We analysed laboratory test data to assess overall costs and cost per pulmonary TB and multidrug-resistant TB (MDR-TB) case diagnosed. Costs were expressed as 2013 Consumer Price Index-adjusted values. RESULTS: Total TB diagnostic costs increased by 43%, from US$440 967 in the smear/culture-based algorithm (April-June 2011) to US$632 262 in the Xpert-based algorithm (April-June 2013). The cost per TB case diagnosed increased by 157%, from US$48.77 (n = 1601) to US$125.32 (n = 1281). The total cost per MDR-TB case diagnosed was similar, at US$190.14 and US$183.86, with 95 and 107 cases diagnosed in the respective algorithms. CONCLUSION: The introduction of the Xpert-based algorithm resulted in substantial cost increases. This was not matched by the expected increase in TB diagnostic efficacy, calling into question the sustainability of this expensive new technology.

Health care workers' gender bias in testing could contribute to missed tuberculosis among women in South Africa.

SETTING: Eight communities with high tuberculosis (TB) prevalence, Western Cape, South Africa. OBJECTIVE: To identify sex differences in TB health-seeking behaviour and diagnosis in primary health care facilities and how this influences TB diagnosis. DESIGN: We used data from a prevalence survey among 30,017 adults conducted in 2010 as part of the Zambia, South Africa Tuberculosis and AIDS Reduction (ZAMSTAR) trial. RESULTS: A total of 1670 (5.4%) adults indicated they had a cough of ⩾2 weeks, 950 (56.9%) of whom were women. Women were less likely to report a cough of ⩾2 weeks (5.1% vs. 6.4%, P < 0.001), but were more likely to seek care for their cough (32.6% vs. 26.9%, P = 0.012). Of all adults who sought care, 403 (80.0%) sought care for their cough at a primary health care (PHC) facility (79.0% women vs. 81.4% men, P = 0.511). Women were less likely to be asked for a sputum sample at the PHC facility (63.3% vs. 77.2%, P = 0.003) and less likely to have a positive sputum result (12.6% vs. 20.7%, P = 0.023). CONCLUSION: The attainment of sex equity in the provision of TB health services requires adherence to testing protocols. Everyone, irrespective of sex, who seeks care for a cough of ⩾2 weeks should be tested.

Optimizing Mycobacterial Culture in Smear-Negative, Human Immunodeficiency Virus-Infected Tuberculosis Cases.

INTRODUCTION: Tuberculosis (TB) is a significant public health problem and the diagnosis in human immunodeficiency virus (HIV)-infected individuals is challenging. The use of mycobacterial culture remains an important complementary tool and optimizing it has important benefits. We sought to determine the effect of an increase in the number of specimens evaluated, addition of nutritional supplementation to the culture medium, sputum appearance and volume on diagnostic yield and time to detection of pulmonary TB among smear-negative, HIV-infected adults. METHODS: In this prospective study conducted at the Tshwane District Hospital and Academic TB Laboratory, Pretoria, South Africa we collected three sputum specimens an hour apart from presumptive TB cases at an antiretroviral treatment site. We analysed specimens from 236 patients. Specimen appearance and volume were recorded. All specimens were processed for culture using both standard and supplemented media. RESULTS: A single specimen identified 79% of PTB cases using standard media; the second and third specimens added 12.5% and 8.3% respectively. Media supplementation, sputum appearance and specimen volume had no effect on culture yield or contamination rates. The mean time to detection was reduced from 19.8 days in standard cultures to 11.8 days in nutrient supplemented cultures (p = 0.002). For every 1 ml increase in sputum volume, time to detection was decreased by a factor of 0.797 (p = 0.011). CONCLUSION: Use of an inexpensive culture supplement substantially reduced time to detection and could contribute to reducing treatment delay among HIV-infected cases.

Assessment of previous tuberculosis status using questionnaires, chest X-rays and computed tomography scans.

SETTING: Accurate diagnosis of previous pulmonary tuberculosis disease (PPTB) status is important clinically and in research. Reliable records of bacteriologically confirmed tuberculosis (TB) are frequently unavailable. OBJECTIVES: To evaluate the use of questionnaires and chest imaging to determine PPTB status in a high TB prevalence population. DESIGN: PPTB status was assessed using two questionnaires, chest X-ray (CXR) and high-resolution chest computed tomography (CT) scans reported by experienced readers. The study population comprised adults aged >40 years diagnosed with obstructive lung disease in a community-based prevalence survey. RESULTS: The Burden of Obstructive Lung Disease (BOLD) questionnaire and a second comprehensive questionnaire (PTbQ) provided a history of PPTB in respectively 38% (n = 41) and 36.4% (n = 39) of 107 participants. On CXR, 43.3% (45/104) had evidence of PPTB, with good inter-reader agreement (κ = 0.73). Changes compatible with PPTB were identified on chest CT in 68.3% (71/104) of the subjects. Questionnaire and CXR had negative predictive values for PPTB of 48% and 47%, respectively, compared to a composite definition. CONCLUSION: Both questionnaire and CXR markedly underestimate the prevalence of previous TB in patients with chronic obstructive pulmonary disease. The combination of a structured questionnaire and CT scan is more useful when a diagnosis of PPTB needs to be ruled out.

Comparing multidrug-resistant tuberculosis patient costs under molecular diagnostic algorithms in South Africa.

SETTING: Ten primary health care facilities in Cape Town, South Africa, 2010-2013. OBJECTIVE: A comparison of costs incurred by patients in GenoType MDRTBplus line-probe assay (LPA) and Xpert MTB/RIF-based diagnostic algorithms from symptom onset until treatment initiation for multidrug-resistant tuberculosis (MDR-TB). METHODS: Eligible patients identified from laboratory and facility records were interviewed 3-6 months after treatment initiation and a cost questionnaire completed. Direct and indirect costs, individual and household income, loss of individual income and change in household income were recorded in local currency, adjusted to 2013 costs and converted to $US. RESULTS: Median number of visits to initiation of MDR-TB treatment was reduced from 20 to 7 (P < 0.001) and median costs fell from US$68.1 to US$38.3 (P = 0.004) in the Xpert group. From symptom onset to being interviewed, the proportion of unemployed increased from 39% to 73% in the LPA group (P < 0.001) and from 53% to 89% in the Xpert group (P < 0.001). Median household income decreased by 16% in the LPA group and by 13% in the Xpert group. CONCLUSION: The introduction of an Xpert-based algorithm brought relief by reducing the costs incurred by patients, but loss of employment and income persist. Patients require support to mitigate this impact.

Integration of TB and ART services fails to improve TB treatment outcomes: comparison of ART/TB primary healthcare services in Cape Town, South Africa.

BACKGROUND: The combined tuberculosis (TB) and HIV epidemics in South Africa (SA) have created enormous operational challenges for a health service that has traditionally run vertical programmes for TB treatment and antiretroviral therapy (ART) in separate facilities. This is particularly problematic for TB/HIV co-infected patients who need to access both services. OBJECTIVE: To determine whether integrated TB facilities had better TB treatment outcomes than single-service facilities in Cape Town, SA. METHODS: TB treatment outcomes were determined for newly registered, adult TB patients (aged > or = 18 years) at 13 integrated ART/TB primary healthcare (PHC) facilities and four single-service PHC facilities from 1 January 2009 to 30 June 2010. A chi2 test adjusted for a cluster sample design was used to compare outcomes by type of facility. RESULTS: Of 13,542 newly registered patients, 10,030 received TB treatment in integrated facilities and 3,512 in single-service facilities. There was no difference in baseline characteristics between the two groups with HIV status determined for 9,351 (93.2%) and 3,227 (91.9%) patients, of whom 6 649 (66.3%) and 2,213 (63%) were HIV-positive in integrated facilities and single-service facilities, respectively. The median CD4+ count of HIV-positive patients was 152 cells/microl (interquartile range (IQR) 71-277) for integrated facilities and 148 cells/microl (IQR 67-260) for single-service facilities. There was no statistical difference in the TB treatment outcome profile between integrated and single-service facilities for all TB patients (p = 0.56) or for the sub-set of HIV-positive TB patients (p = 0.58) CONCLUSION: This study did not demonstrate improved TB treatment outcomes in integrated PHC facilities and showed that the provision of ART in the same facility as TB services was not associated with lower TB death and default rates.

Symptom reporting among prevalent tuberculosis cases who smoke, are HIV-positive or have hyperglycaemia.

Data from a tuberculosis (TB) prevalence survey conducted in 24 communities in Zambia and the Western Cape, South Africa, January-December 2010, were analysed to determine the influence of smoking, hyperglycaemia and human immunodeficiency virus (HIV) infection on TB symptom reporting in culture-confirmed TB cases. Of 123 790 adults eligible for enrolment, 90 601 (73%) consented and 64 463 had evaluable sputum samples. ORs and 95%CIs were calculated using a robust standard errors logistic regression model adjusting for clustering at community level. HIV-positive TB cases were more likely to report cough, weight loss, night sweats and chest pain than non-HIV-positive TB cases. TB cases who smoked or had hyperglycaemia did not report symptoms differently from cases without these comorbidities.

Des données émanant d';une enquête de prévalence de la tuberculose (TB), réalisées dans 24 communautés de Zambie et de la province du Cap Ouest en Afrique du Sud de janvier à décembre 2010, ont été analysées afin de déterminer l'influence du tabagisme, de l'hyperglycémie et de l'infection par le virus de l'immunodéficience humaine (VIH) sur l'expression des symptômes de TB dans des cas de TB confirmés par la culture. Sur 123 790 adultes éligibles, 90 601 (73%) ont consenti et 64 463 ont produit des échantillons de crachats utilisables. Les OR et les IC à 95% ont été calculés grâce à un modèle de régression logistique des erreurs standard robustes en ajustant le regroupement au niveau des communautés. Les patients atteints de TB et VIH positifs rapportaient plus volontiers de la toux, une perte de poids, des sueurs nocturnes et des douleurs thoraciques que les patients non VIH positifs. Par contre, les cas de TB qui fumaient ou présentaient une hyperglycémie ne signalaient pas de symptômes différents des patients qui n'avaient pas ces co-morbidités.

En el presente estudio se analizaron los datos de una encuesta reciente sobre la prevalencia de tuberculosis (TB), que se había llevado a cabo en 24 comunidades en Zambia y en el Cabo Occidental de Suráfrica de enero a diciembre del 2010, con el fin de determinar la influencia del tabaquismo, la hiperglucemia y la infección por el virus de la inmunodeficiencia humana (VIH) sobre los síntomas de TB que refieren los pacientes con diagnóstico de TB confirmada por cultivo. De los 123 790 adultos aptos para el estudio, 90 601 dieron su consentimiento (73%) y 64 463 aportaron muestras de esputo adecuadas. Se calculó el cociente de posibilidades y el intervalo de confianza del 95% mediante un modelo consistente de regresión logística y errores estándar, tras corregir la agregación de los datos por comunidad. Fue más frecuente que los pacientes con TB que eran positivos frente al VIH refirieran tos, pérdida de peso, sudoración nocturna y dolor torácico que los pacientes sin esta coinfección. No hubo diferencia en los síntomas comunicados por los pacientes tuberculosos que fumaban o que presentaban hiperglucemia, en comparación con los pacientes sin estas enfermedades concurrentes.

Factors influencing increased expertise for a sustainable workforce at a research centre in South Africa.

SETTING: The Desmond Tutu Tuberculosis (TB) Centre (DTTC), Stellenbosch University, South Africa. OBJECTIVES: 1) To determine whether access to designated funding is associated with the development of expertise in employees, and 2) which other factors are associated with the development of expertise in employees. DESIGN: This was a retrospective study. The target population consisted of all employees at the DTTC during the period 1 January 2004 to 31 December 2011. Improvement in expertise during employment was the primary outcome; the secondary outcome was an increase in educational level linked to the National Qualifications Framework. RESULTS: There was no association between access to funding and expertise development, but an association between the number of months employed and improvement of expertise during employment was observed (OR 1.03, 95%CI 1.02-1.04, P < 0.001), controlling for age at appointment, sex, access to designated funding and education level. CONCLUSION: The study shows that almost a third of employees increased their expertise, more than 90% had access to designated funding and personnel employed for a longer duration were more likely to experience improvements in expertise. We encourage research organisations in low- and middle-income countries to implement strategies to retain employees in order to build their expertise.

Contexte : Le Centre Antituberculeux Desmond Tutu (DTTC), à l'Université de Stellenbosch, en Afrique du Sud.Objectifs : 1) Déterminer si l'accès au financement est associé au développement d'une expertise chez les employés, et 2) déterminer quels autres facteurs sont associés au développement de l'expertise des employés.Schéma : Cette étude était rétrospective. La population cible était constituée par les employés du DTTC entre le 1e janvier 2004 et le 31 décembre 2011. L'amélioration de l'expertise pendant la période de fonction était le premier résultat attendu ; le deuxième était une augmentation du niveau de connaissances en relation avec le Cadre National de Certification.Résultats : Il n'a pas été démontré d'association entre l'accès au financement et le développement de l'expertise, mais on a mis en évidence une association entre le nombre de mois de travail et cette amélioration (OR 1.03 ; IC95% 1,02­1.04 ; P< 0,001), en contrôlant l'âge lors de l'entrée en fonction, le sexe, l'accès au financement et le niveau d'instruction.Conclusion : L'étude montre que près d'un tiers du personnel a accru son expertise, plus de 90% ont eu accès au financement et que les personnes employées pendant une durée plus longue avaient davantage de chances d'améliorer leur expertise. Nous encourageons les organismes de recherche des pays à revenu faible et moyen à mettre en œuvre des stratégies visant à retenir leur personnel afin de renforcer leur expertise.

Marco de referencia: El Centro Desmond Tutu de atención de la tuberculosis (DTTC) de la Universidad Stellenbosch en Suráfrica.Objetivos: 1) Determinar si la obtención de atribución de financiamientos contribuye a perfeccionar la competencia profesional de los empleados; y 2) definir los demás factores que fomentan el mejoramiento de la pericia de los profesionales.Método: Fue este un estudio retrospectivo de los empleados del DTTC del 1° de enero del 2004 al 31 de diciembre del 2011. El principal criterio de evaluación fue el perfeccionamiento de la competencia profesional de los empleados durante el tiempo de ocupación del cargo. El criterio secundario fue el progreso académico de los profesionales, según los criterios del Marco Nacional de Cualificaciones.Resultados: No se observó ninguna asociación entre el acceso al financiamiento y el mejoramiento de las competencias, pero la duración en meses en el empleo se asoció con un progreso en los conocimientos y la experiencia de los empleados (OR 1,03; IC95% de 1,02 a 1,04; P < 0,001), una vez corregidos los datos en función de la edad del nombramiento, el sexo, el acceso a la atribución de financiamiento y el grado de instrucción.Conclusión: Los resultados del estudio ponen de manifiesto que cerca de un tercio de los empleados perfeccionó sus competencias, más del 90% contaba con acceso a la atribución de financiamiento y que era más probable que las personas empleadas por períodos más prolongados mejorasen sus conocimientos teóricos y prácticos. Se recomienda a las organizaciones de investigación de los países con recursos medianos y bajos que introduzcan estrategias encaminadas a fidelizar a sus empleados, con el fin de mejorar y consolidar las competencias.

Sex-related trends in non-conversion of new smear-positive tuberculosis patients in the Free State, South Africa.

SETTING: Free State Province, South Africa. OBJECTIVE: To examine sex-specific trends in 2-month sputum smear non-conversion in new sputum smear-positive tuberculosis (TB) cases during a period when the DOTS strategy was operative. DESIGN: A retrospective cohort study of TB cases registered between 2003 and 2009 was conducted. Non-conversion was indicated by a positive 2-month sputum smear result. Descriptive and generalised linear model analyses were performed and sex-specific trends in 2-month sputum smear non-conversion rates estimated. RESULTS: Overall, 2-month sputum smear non-conversion rates were 12.5% in males and 9.3% in females. Non-conversion was significantly associated with age in males (P < 0.001). Non-conversion rates declined significantly between 2003 and 2009: from 15.9% to 10.8% in males (P < 0.001) and from 12.0% to 6.6% in females (P < 0.001). The average rate of decline of non-conversion was higher among females (1.0%, 95%CI 0.8-1.2) than among males (0.8%, 95%CI 0.5-1.0). By 2009, males had a 60% higher risk of non-conversion than females (RR 1.60, CI 1.37-1.86). CONCLUSION: The decline in the trend of 2-month sputum smear non-conversion confirms the relative success of the DOTS strategy in TB control, with better performance among females than males. Interventions should consider the sex and age of patients to improve the 2-month sputum smear-conversion rate.

Contexte : Province de l'Etat Libre, Afrique du Sud.Objectif : Examiner les tendances en fonction du sexe de la nonconversion des frottis de crachats après 2 mois chez des nouveaux cas de tuberculose (TB) à frottis positifs pendant une période où la stratégie DOTS opérait.Schéma : Réalisation d'une étude rétrospective de cohorte des cas de TB enregistrés entre 2003 et 2009. La non-conversion était définie par un résultat de frottis positif après 2 mois de traitement. Des analyses descriptives et de modèles linéaires généralisés ont été réalisées et les tendances de non conversion à 2 mois en fonction du sexe ont été estimées.Résultats : Le taux d'ensemble de non conversion était de 12,5% chez les hommes et de 9,3% chez les femmes. La non conversion était significativement associée à l'âge chez les hommes (P < 0,001). Le taux de non conversion a significativement diminué entre 2003 et 2009 de 15,9% à 10,8% chez les hommes (P < 0,001) et de 12% à 6,6% chez les femmes (P < 0,001). Le taux moyen de déclin de la non-conversion était plus élevé chez les femmes à 1% (IC95% 0,8­1,2%) que chez les hommes à 0,8% (IC95% 0,5­1%). En 2009, le risque de non conversion était plus élevé de 60% chez les hommes (RR 1,60; IC95% 1,37­1,86).Conclusion : Le déclin de la tendance à la non-conversion du frottis de crachats après 2 mois de traitement a mis en évidence le succès relatif de la stratégie DOTS dans la lutte contre la TB, avec un meilleur résultat chez les femmes que chez les hommes. Les interventions devraient tenir compte du sexe et de l'âge des patients afin d'améliorer le taux de conversion du frottis de crachats à 2 mois.

Marco de referencia: La Provincia del Estado Libre en África del Sur.Objetivo: Examinar las tendencias específicas de sexo, con respecto a la falta de conversión de la baciloscopia del esputo a los 2 meses de tratamiento, en los casos nuevos de tuberculosis (TB) con baciloscopia positiva, durante un período de aplicación de la estrategia DOTS.Métodos: Se llevó a cabo un estudio retrospectivo de cohortes de los casos de TB registrados entre el 2003 y el 2009. La falta de conversión se definió como la obtención de un resultado positivo de la baciloscopia del esputo a los 2 meses. Se practicaron análisis con modelos generales lineales y se calculó la tendencia de la falta de conversión a los 2 meses, según las tasas específicas de sexo.Résultados: En general, las tasas de falta de conversión fueron 12,5% en los hombres y 9,3% en las mujeres. La falta de conversión se asoció de manera significativa con la edad en los hombres (P < 0,001). El índice de falta de conversión disminuyó de manera considerable entre el 2003 y el 2009, de 15,9% a 10,8% en los hombres (P < 0,001) y de 12,0% a 6,6% en las mujeres (P < 0,001). La tasa promedio de disminución de la falta de conversión en las mujeres de 1,0 % (IC95% de 0,8% a 1,2%) fue más alta que la tasa de 0,8% en los hombres (IC95% de 0,5% a 1,0%). En el 2009, los hombres exhibieron un riesgo de falta de conversión superior en 60,0 % a las mujeres (RR 1,60; IC95% de 1,37 a 1,86).Conclusión: La tendencia a la disminución de la falta de conversión de la baciloscopia a los 2 meses de tratamiento define la eficacia relativa de la estrategia DOTS en el control de la TB y ofrece un mejor rendimiento en las mujeres que en los hombres. Con el propósito de mejorar las tasas de conversión, las intervenciones deben tener en cuenta el sexo y la edad de los pacientes.

Tuberculosis patients in primary care do not start treatment. What role do health system delays play?

SETTING: Primary health care facilities in five provinces of South Africa. OBJECTIVE: To investigate the association between the proportion of sputum results with a prolonged smear turnaround time and the proportion of smear-positive tuberculosis (TB) cases initially lost to follow-up. DESIGN: The unit of investigation was a primary health care facility and the outcome was the initial loss to follow-up rate per facility, which was calculated by comparing the sputum register with the TB treatment register. A prolonged turnaround time was defined as more than 48 h from when the sputum sample was documented in the sputum register to receipt of the result at the facility. RESULTS: The mean initial loss to follow-up rate was 25% (95%CI 22-28). Smear turnaround time overall was inversely associated with initial loss to follow-up (P = 0.008), when comparing Category 2 (33-66% turnaround time within 48 h) with Category 1 (0-32%) (OR 0.73, 95%CI 0.48-1.13, P = 0.163) and when comparing Category 3 (67-100%) with Category 1 (OR 0.62, 95%CI 0.39-0.99, P = 0.045). The population preventable fraction of initial loss to follow-up (when turnaround time was <48 h in ≥67% of smear results) was 21%. CONCLUSION: Initial loss to follow-up should be reported as part of the TB programme to ensure that patients are initiated on treatment to prevent transmission within communities.

Tuberculosis cases missed in primary health care facilities: should we redefine case finding?

SETTING: This study was conducted in Cape Town in two primary health care facilities in a sub-district with a high prevalence of bacteriologically confirmed pulmonary tuberculosis (TB). OBJECTIVE: To determine the proportion of adults with respiratory symptoms who attend health care facilities but are not examined for nor diagnosed with TB in facilities where routine TB diagnosis depends on passive case finding. DESIGN: A total of 423 adults with respiratory symptoms exiting primary health care services were consecutively enrolled during April-July 2011. RESULTS: Twenty-one (5%) participants were diagnosed with culture-positive TB. None had sought care at the facility for their respiratory symptoms, none were asked about respiratory symptoms during their visit and none were asked to produce a sputum sample. Nine cases had attended the facility for reasons regarding their own health, while 12 cases were accompanying someone else attending the facility, or for another reason. CONCLUSION: Patients with infectious TB attend primary health care facilities, but are not recognised and diagnosed as cases. Health care staff should search actively within facilities for cases who attend the health care services to ensure that cases are not missed. Intensified case finding should start within the facility, and should not be limited to patients who report respiratory symptoms or who are human immunodeficiency virus positive.