Tobacco smoking clusters in households affected by tuberculosis in an individual participant data meta-analysis of national tuberculosis prevalence surveys: Time for household-wide interventions?

Tuberculosis (TB) and non-communicable diseases (NCD) share predisposing risk factors. TB-associated NCD might cluster within households affected with TB requiring shared prevention and care strategies. We conducted an individual participant data meta-analysis of national TB prevalence surveys to determine whether NCD cluster in members of households with TB. We identified eligible surveys that reported at least one NCD or NCD risk factor through the archive maintained by the World Health Organization and searching in Medline and Embase from 1 January 2000 to 10 August 2021, which was updated on 23 March 2023. We compared the prevalence of NCD and their risk factors between people who do not have TB living in households with at least one person with TB (members of households with TB), and members of households without TB. We included 16 surveys (n = 740,815) from Asia and Africa. In a multivariable model adjusted for age and gender, the odds of smoking was higher among members of households with TB (adjusted odds ratio (aOR) 1.23; 95% CI: 1.11-1.38), compared with members of households without TB. The analysis did not find a significant difference in the prevalence of alcohol drinking, diabetes, hypertension, or BMI between members of households with and without TB. Studies evaluating household-wide interventions for smoking to reduce its dual impact on TB and NCD may be warranted. Systematically screening for NCD using objective diagnostic methods is needed to understand the actual burden of NCD and inform comprehensive interventions.

Expert Opinion on Addressing the Gap in Injection Technique and Needle Reuse for People with Diabetes in Indonesia.

The use of insulin for patients with diabetes mellitus in Indonesia appears to be under expectation; moreover, there are gaps in knowledge regarding the proper injection technique and pen needle reuse by both healthcare professionals (HCPs) and patients. To address these issues, a scientific expert meeting was held with the participation of endocrinologists and public health specialist from many different organizations in Indonesia to identify the challenges and problem related to injection technique, high pen needle reuse rate, and the need of all stakeholders. The experts agreed that it is necessary to ensure physicians to start the initiation phase as early as indicated, continue optimizing its dosage to reach targeted blood sugar based on guideline, and involve all relevant stakeholders to improve insulin distribution and patient access in every primary care facility in order to optimize the use of insulin or other injectable diabetes medications in Indonesia. Additionally, the experts believed that education on proper injection technique and improved reuse rate of pen needle is necessary. To date, Indonesian Diabetes Educators Association (IDEA/PEDI) has established guideline on injection technique. There are also recommendations on injection technique and needle reuse from Indonesian Society of Endocrinology (PERKENI) and Forum for Injection Technique & Therapy: Expert Recommendations (FITTER); however, this guideline/recommendation should be disseminated more widely among HCPs. In addition, cost-effectiveness studies based on local data are needed to propose and convince the Payors and other stakeholders. This article can be used as a guidance for HCPs and policymakers to improve current practice on injection technique, pen needle reuse, needle prescription and reimbursement policy in Indonesia and elsewhere.

Association of diabetes, smoking, and alcohol use with subclinical-to-symptomatic spectrum of tuberculosis in 16 countries: an individual participant data meta-analysis of national tuberculosis prevalence surveys.

Background: Non-communicable diseases (NCDs) and NCD risk factors, such as smoking, increase the risk for tuberculosis (TB). Data are scarce on the risk of prevalent TB associated with these factors in the context of population-wide systematic screening and on the association between NCDs and NCD risk factors with different manifestations of TB, where ∼50% being asymptomatic but bacteriologically positive (subclinical). We did an individual participant data (IPD) meta-analysis of national and sub-national TB prevalence surveys to synthesise the evidence on the risk of symptomatic and subclinical TB in people with NCDs or risk factors, which could help countries to plan screening activities. Methods: In this systematic review and IPD meta-analysis, we identified eligible prevalence surveys in low-income and middle-income countries that reported at least one NCD (e.g., diabetes) or NCD risk factor (e.g., smoking, alcohol use) through the archive maintained by the World Health Organization and by searching in Medline and Embase from January 1, 2000 to August 10, 2021. The search was updated on March 23, 2023. We performed a one-stage meta-analysis using multivariable multinomial models. We estimated the proportion of and the odds ratio for subclinical and symptomatic TB compared to people without TB for current smoking, alcohol use, and self-reported diabetes, adjusted for age and gender. Subclinical TB was defined as microbiologically confirmed TB without symptoms of current cough, fever, night sweats, or weight loss and symptomatic TB with at least one of these symptoms. We assessed heterogeneity using forest plots and I2 statistic. Missing variables were imputed through multi-level multiple imputation. This study is registered with PROSPERO (CRD42021272679). Findings: We obtained IPD from 16 national surveys out of 21 national and five sub-national surveys identified (five in Asia and 11 in Africa, N = 740,815). Across surveys, 15.1%-56.7% of TB were subclinical (median: 38.1%). In the multivariable model, current smoking was associated with both subclinical (OR 1.67, 95% CI 1.27-2.40) and symptomatic TB (OR 1.49, 95% CI 1.34-1.66). Self-reported diabetes was associated with symptomatic TB (OR 1.67, 95% CI 1.17-2.40) but not with subclinical TB (OR 0.92, 95% CI 0.55-1.55). For alcohol drinking ≥ twice per week vs no alcohol drinking, the estimates were imprecise (OR 1.59, 95% CI 0.70-3.62) for subclinical TB and OR 1.43, 95% CI 0.59-3.46 for symptomatic TB). For the association between current smoking and symptomatic TB, I2 was high (76.5% (95% CI 62.0-85.4), while the direction of the point estimates was consistent except for three surveys with wide CIs. Interpretation: Our findings suggest that current smokers are more likely to have both symptomatic and subclinical TB. These individuals can, therefore, be prioritised for intensified screening, such as the use of chest X-ray in the context of community-based screening. People with self-reported diabetes are also more likely to have symptomatic TB, but the association is unclear for subclinical TB. Funding: None.

HIV prevalence and risk behaviours among injecting drug users in six indonesian cities implications for future HIV prevention programs.

BACKGROUND: The HIV prevalence among injecting drug users (IDUs) in Indonesia reached 50% in 2005. While drug use remains illegal in Indonesia, a needle and syringe program (NSP) was implemented in 2006. METHODS: In 2007, an integrated behavioural and biological surveillance survey was conducted among IDUs in six cities. IDUs were selected via time-location sampling and respondent-driven sampling. A questionnaire was administered face-to-face. IDUs from four cities were tested for HIV, syphilis, gonorrhoea and chlamydia. Factors associated with HIV were assessed using generalized estimating equations. Risk for sexual transmission of HIV was assessed among HIV-positive IDUs. RESULTS: Among 1,404 IDUs, 70% were daily injectors and 31% reported sharing needles in the past week. Most (76%) IDUs received injecting equipment from NSP in the prior week; 26% always carried a needle and those who didn't, feared police arrest. STI prevalence was low (8%). HIV prevalence was 52%; 27% among IDUs injecting less than 1 year, 35% among those injecting for 1-3 years compared to 61% in long term injectors (p < 0.001). IDUs injecting for less than 3 years were more likely to have used clean needles in the past week compared to long term injectors (p < 0.001). HIV-positive status was associated with duration of injecting, ever been imprisoned and injecting in public parks. Among HIV-infected IDUs, consistent condom use last week with steady, casual and commercial sex partners was reported by 13%, 24% and 32%, respectively. CONCLUSIONS: Although NSP uptake has possibly reduced HIV transmission among injectors with shorter injection history, the prevalence of HIV among IDUs in Indonesia remains unacceptably high. Condom use is insufficient, which advocates for strengthening prevention of sexual transmission alongside harm reduction programs.

Sexual risk taking, STI and HIV prevalence among men who have sex with men in six Indonesian cities.

Using surveillance data on men who have sex with men (MSM) from six Indonesian cities, this article reports prevalence of sexual risk taking, HIV and other sexually transmitted infections. Factors associated with HIV, other STIs and consistent condom use were assessed. Behavioral data were collected from 1,450 MSM, among whom 749 were tested for HIV and syphilis and 738 for gonorrhea and Chlamydia. Associations were assessed using multivariate logistic regression. Over 80% of MSM knew HIV transmission routes, 65% of MSM had multiple male sexual partners, 27% unprotected anal sex with multiple male partners, and 27% sex with a female in the prior month. Consistent condom use ranged from 30 to 40% with male partners and 20 to 30% with female partners, depending upon partner type. HIV prevalence averaged 5.2%, but was 8.0% in Jakarta. Prevalence of rectal gonorrhea or Chlamydia was 32%. Multivariate analyses revealed recent methamphetamine use and current rectal gonorrheal or chlamydial infection to be associated with HIV infection. The data confirm diverse sexual networks and substantial sexual risk-taking, despite relatively high levels of education and HIV-related knowledge. In addition to promoting partner reduction and more consistent condom and lubricant use, prevention efforts must also address substance abuse.

HIV, sexually transmitted infections, and sexual risk behavior among transgenders in Indonesia.

Behavioral surveillance was undertaken among 1,150 male-to-female transgenders (waria) in Java, Indonesia, 2007; samples were collected for HIV and STI testing (n = 748). Almost all waria had ever sold sex (median duration 10 years). Prevalence of HIV was 24.4%, syphilis 26.8% and rectal gonorrhea and/or chlamydia 47.0%. Syphilis and rectal STIs were associated with HIV infection. Consistent condom use during receptive anal sex with clients was reported by 35.9% waria and was higher among those who visited an STI clinic and who knew their HIV status. Efforts should continue to strengthen behavior change and STI care in future HIV prevention programs.

Is the bed capture enzyme immunoassay useful for surveillance in concentrated epidemics? The case of female sex workers in Indonesia.

Although the BED capture enzyme immunoassay (BED-CEIA) tends to over-estimate HIV incidence in general population epidemics, its limitations may be less relevant to some sub-populations in concentrated epidemics. This study assesses the plausibility of BED-CEIA estimates for female sex workers (FSWs) in Indonesia. Data were derived from a cross-sectional anonymous linked behavioral and biological surveillance survey. Independent samples of 2,917 direct and indirect FSWs, were gathered from seven and five cities, respectively, via three-stage time-location sampling. Participants provided behavioral information, venous blood and vaginal swabs. Specimens testing positive for HIV were subjected to BED-CEIA to identify recent infections. The median duration of sex work was 12 months. The estimated HIV prevalence was 8.2% and the incidence was 4.1 per 100 person years, slightly lower than an Asian Epidemic Model (AEM) estimate. HIV incidence was higher among: direct FSWs (p<0.001), those reporting genital ulcers in the past year (p<0.001), those with active syphilis (p=0.017), and those not receiving periodic presumptive treatment for STIs during the previous 6 months (p=0.045). Low general population HIV prevalence, short durations of sex work and low ART coverage of those eligible for treatment make it unlikely that HIV incidence estimates for FSWs in Indonesia are distorted by long-standing infections and viral suppression. External consistency with model-based estimates and internal consistency in regard to known risk factors for HIV infection add to the plausibility of the estimates. Pending advances in methods for estimating HIV incidence, it may be premature to summarily dismiss the BED-CEIA in concentrated HIV epidemics.