Characteristics of TPT initiation and completion among people living with HIV.

BACKGROUND: TB preventive treatment (TPT) reduces morbidity and mortality among people living with HIV (PLHIV). Despite the successful scale-up of TPT in Malawi, monitoring and evaluation have been suboptimal. We utilized the Malawi Population-Based HIV Impact Assessment (MPHIA) 2020-2021 survey data to estimate TPT uptake and completion among self-reported HIV-positive persons. METHODS: We estimated the proportion of HIV-positive respondents who had ever undergone TPT, and determined the percentage of those currently on TPT who had completed more than 6 months of treatment. Bivariate and multivariable logistic regression were performed to calculate the odds ratios for factors associated with ever-taking TPT. All variables were self-reported, and the analysis was weighted and accounted for in the survey design. RESULTS: Of the HIV+ respondents, 38.8% (95% CI 36.4-41.3) had ever taken TPT. The adjusted odds of ever taking TPT were 8.0 and 5.2 times as high in the Central and Southern regions, respectively, compared to the Northern region; 1.9 times higher among those in the highest wealth quintile, and 2.1 times higher for those on antiretroviral therapy >10 years. Of those currently taking TPT, 56.2% completed >6 months of TPT. CONCLUSION: These results suggest low TPT uptake and >6 months' completion rates among self-reported HIV+ persons. Initiatives to create demand and strengthen adherence would improve TPT uptake.

CONTEXTE: Le traitement préventif de la TB (TPT) réduit la morbidité et la mortalité chez les personnes vivant avec le VIH (PVVIH). Malgré l'extension réussie du TPT au Malawi, le suivi et l'évaluation n'ont pas été optimaux. Nous avons utilisé les données de l'enquête MPHIA (Malawi Population-Based HIV Impact Assessment) 2020­2021 pour estimer l'adoption et l'achèvement du TPT parmi les personnes se déclarant séropositives. MÉTHODES: Nous avons estimé la proportion de répondants séropositifs qui avaient déjà subi un TPT et déterminé le pourcentage de ceux qui sont actuellement sous TPT et qui ont terminé plus de 6 mois de traitement. Une régression logistique bivariée et multivariable a été effectuée pour calculer les rapports de cotes des facteurs associés au fait d'avoir déjà pris un TPT. Toutes les variables étaient autodéclarées et l'analyse a été pondérée et prise en compte dans la conception de l'enquête. RÉSULTATS: Parmi les répondants séropositifs, 38,8% (IC 95% 36,4­41,3) avaient déjà pris du TPT. Les probabilités ajustées de prise de TPT étaient 8,0 et 5,2 fois plus élevées dans les régions du centre et du sud, respectivement, que dans la région du nord ; 1,9 fois plus élevées chez les personnes appartenant au quintile de richesse le plus élevé, et 2,1 fois plus élevées chez les personnes suivant une thérapie antirétrovirale depuis plus de 10 ans. Parmi ceux qui prennent actuellement un TPT, 56,2% ont terminé >6 mois de TPT. CONCLUSION: Ces résultats suggèrent un faible taux d'utilisation du TPT et des taux d'achèvement de >6 mois parmi les personnes déclarées séropositives. Des initiatives visant à créer une demande et à renforcer l'adhésion permettraient d'améliorer l'utilisation du TPT.

Community-level variation in TB testing history in Blantyre, Malawi.

SETTING: Equitable access to TB testing is vital for achieving global diagnosis and treatment targets, but access to diagnostic services is often worse in poorer communities. The SCALE (Sustainable Community-wide Active case-finding for Lung hEalth) survey estimated TB prevalence in Blantyre City, Malawi, and recorded previous engagement with TB services.OBJECTIVE: To explore local variation in the prevalence of ever-testing for TB in Blantyre and investigate potential socio-economic drivers.DESIGN: We fit a mixed-effects model to self-reported prior TB testing from survey participants across 72 neighbourhood clusters, adjusted for sex, age and HIV status and with cluster-level random intercepts. We then evaluated to what extent cluster-level variation was explained by two alternate poverty indicators.RESULTS: We observed substantial variation between clusters in previous TB testing, with little correlation between neighbouring clusters. Individuals residing in less affluent households, on average, had lower odds of having undergone prior testing. However, adjusting for poverty did not explain the cluster-level variations observed.CONCLUSION: Despite a decade of increased active case-finding efforts, access to TB testing is inconsistent across the population of Blantyre. This likely reflects health inequities that also apply to TB testing in many other settings, and motivates collection and analysis of TB testing data to identify the drivers behind these inequities.

TB screening, prevention and treatment cascade in a Malawi prison.

BACKGROUND Incarcerated individuals, especially in high HIV and TB burden settings, are at increased risk of latent TB infection and/or TB disease. We implemented a comprehensive HIV-TB intervention in a Malawi prison and studied its feasibility.METHODS Between February and December 2019, consenting individuals underwent screening for HIV, TB infection and TB disease. HIV-positive individuals without TB disease were treated with a fixed-dose combination of isoniazid, cotrimoxazole and vitamin B6 (INH-CTX-B6). HIV-negative persons with TB infection received 12 weeks of isoniazid and rifapentine (3HP).RESULTS Of 1,546 consenting individuals, 1,498 (96.9%) were screened and 1,427 (92.3%) included in the analysis: 96.4% were male, the median age was 31 years (IQR 25-38). Twenty-nine (2.1%) participants were diagnosed with TB disease, of whom 89.7% started and 61.5% completed TB treatment. Of the 1,427 included, 341 (23.9%) were HIV-positive, of whom 98.5% on antiretroviral therapy and 95% were started on INH-CTX-B6. Among 1,086 HIV-negative participants, 1,015 (93.5%) underwent the tuberculin skin test (TST), 670 (65.9%) were TST-positive, 666 (99.4%) started 3HP and 570 (85.5%) completed 3HP treatment.CONCLUSION A comprehensive TB screening and treatment package among incarcerated individuals was acceptable and feasible, and showed high prevalence of HIV, TB disease and TB infection. Treatment uptake was excellent, but treatment completion needs to be improved. Greater investment in comprehensive HIV-TB services, including access to shorter TB regimens and follow-up upon release, is needed for incarcerated individuals.

Factors affecting tuberculosis health message recall 2 years after active case finding in Blantyre, Malawi.

SETTING: Urban slums, Blantyre, Malawi. OBJECTIVE: To explore tuberculosis (TB) community-wide active case finding (cwACF) recall and accompanying messaging 2 years after the intervention. DESIGN: This mixed-methods study used population-weighted random cluster sampling to select three cwACF-receiving and three non-cwACF-receiving neighbourhoods in Blantyre. Qualitative data were collected using 12 focus group discussions (community peer-group members) and five in-depth interviews (TB officers) with script guides based on the concepts of the Health Belief Model (HBM). Thematic analysis was used to explore transcripts employing deductive coding. Questionnaires completed by focus group participants were used to collect quantitative data, providing a 'knowledge score' evaluated through univariate/multivariate analysis, analysis of variance and multiple linear regression. RESULTS: Community peer-group participants (n = 118) retained high awareness and positive opinions of cwACF and recognised the relationship between early diagnosis and reduced transmission, considering cwACF to have prompted subsequent health-seeking behaviour. TB-affected individuals (personal/family: 47.5%) had significantly higher knowledge scores than unaffected individuals (P = 0.039), but only if resident in cwACF-receiving neighbourhoods (P = 0.005 vs. P = 0.582), implying effect modification between exposures, albeit statistically under-powered (P = 0.229). CONCLUSION: Consistent with epidemiological evidence and HBM theory, cwACF may have a permanent impact on knowledge and behaviour, particularly in communities with a high prevalence of TB-affected individuals. Behaviour change strategies should be explicitly included in cwACF planning and evaluation.

Characteristics and management of presumptive tuberculosis in public health facilities in Malawi, 2014-2016.

Setting: Public health facilities providing tuberculosis (TB) and human immunodeficiency virus (HIV) services in Malawi. Objectives: Using routinely collected health service delivery data to describe trends in HIV ascertainment and use of the Xpert® MTB/RIF assay to diagnose TB among HIV-positive presumptive TB cases. Design: This was an implementation study of presumptive TB cases who sought care from 21 facilities between April 2014 and June 2016. Descriptive statistics were used to summarise patient, facility and service level characteristics. Results: Of 28 567 presumptive TB cases analysed, 23 198 (81%) had known HIV status. The proportion of ascertained HIV status in presumptive TB cases increased over the study period. HIV prevalence was 49%, with 73% of HIV-positive presumptive TB cases on antiretroviral therapy. Access to Xpert ranged between 37% and 63% per quarter among HIV-positive presumptive TB patients with smear-negative sputum results. Of 7829 patients with documented Xpert results, 68% were HIV-positive. Conclusion: After the introduction of registers with HIV-related variables, HIV ascertainment among presumptive TB cases increased over time. Access to Xpert was suboptimal among HIV-positive presumptive TB cases. Further collaboration between national TB and HIV programmes may facilitate increased use of Xpert for HIV-positive patients with presumptive TB who seek care in public health facilities.

Contexte : Structures de santé publiques offrant des services de la tuberculose (TB) et du virus de l'immunodéficience humaine (VIH) au Malawi.Objectifs : Utilisant des données recueillies en routine de prestation des services de santé, décrire les tendances de la vérification du VIH et de l'utilisation du test Xpert® MTB/RIF afin de diagnostiquer la TB parmi les cas présumés de TB qui sont VIH positifs.Schéma : Etude de mise en œuvre des cas présumés de TB qui ont sollicité des soins dans 21 structures entre avril 2014 et juin 2016. Nous avons utilisé des statistiques descriptives pour résumer les caractéristiques des patients, des structures et des services.Résultats : Sur les 28 567 cas présumés de TB qui ont été analysés, 23 198 (81%) connaissaient leur statut VIH. La proportion de statuts VIH vérifiés parmi les cas de TB présumés a augmenté tout au long de la période d'étude. La prévalence du VIH a été de 49%, avec 73% des patients VIH positifs présumés TB sous traitement antirétroviral. L'accès à Xpert était entre 37% et 63% par trimestre parmi les patients VIH positifs présumés TB avec des résultats de frottis de crachats négatifs. Sur les 7829 patients ayant des résultats documentés d'Xpert, 68% ont été VIH positifs.Conclusion : Après l'introduction des registres comportant des variables liées au statut VIH, la constatation du VIH parmi les cas présumés de TB a augmenté dans le temps. L'accès à Xpert a été sous-optimal parmi les cas de TB présumés VIH-positifs. Davantage de collaboration entre les programmes nationaux TB et VIH pourrait faciliter une utilisation accrue d'Xpert pour les patients VIH positifs avec une présomption de TB qui sollicitent des soins dans des structures de santé publiques.

Marco de referencia: Los establecimientos públicos de atención de salud que prestan servicios relacionados con la tuberculosis (TB) y la infección por el virus de la inmunodeficiencia humana (VIH) en Malawi.Objetivos: A partir de los datos recogidos de manera sistemática sobre la prestación de los servicios de salud, describir la evolución de la determinación de la situación frente al VIH y de la utilización de la prueba Xpert® MTB/RIF para el diagnóstico de TB, en los casos positivos frente al VIH con presunción clínica de esta enfermedad.Método: Se llevó a cabo un estudio de implementación de los casos con presunción de TB que buscaron atención en 21 centros, de abril 2014 a junio 2016. Se utilizaron estadísticas descriptivas a fin de resumir las características de los pacientes, los establecimientos y los servicios.Resultados: De los 28 567 casos con presunción de TB analizados, 23 198 conocían su situación frente al VIH (81%). La proporción de determinación de la situación frente al VIH en los casos analizados aumentó durante el período del estudio. La prevalencia de infección por el VIH fue 49% y el 73% de estos casos recibía tratamiento antirretrovírico. El acceso a la prueba Xpert osciló entre 37% y 63% por trimestre en los pacientes positivos frente al VIH con presunción de TB y resultados negativos de la baciloscopia de esputo. De los 7829 pacientes con resultado de la prueba Xpert, en el 68% la prueba fue positiva.Conclusión: Tras la introducción de los registros que comportan variables relacionadas con el VIH, la determinación de la situación frente al VIH en los casos con presunción de TB ha aumentado en el transcurso del tiempo. El acceso a la prueba Xpert fue deficiente en los pacientes positivos frente al VIH, con presunción clínica de TB. Una mayor colaboración entre los programas nacionales contra la TB y el VIH facilitaría la utilización de la prueba Xpert en los pacientes seropositivos con presunción de TB que buscan atención en los centros públicos de atención de salud.

The second sputum sample complicates tuberculosis diagnosis for women: a qualitative study from Malawi.

SETTING: District hospital and peripheral health care facilities in Balaka District, Malawi. OBJECTIVE: To identify barriers encountered by women in submitting a second sputum sample. DESIGN: Focus-group discussions and semi-structured interviews. RESULTS: Women encounter barriers at several levels: personal, cultural, socio-economic and health care system. Personal, cultural and socio-economic barriers include the fear of a tuberculosis (TB) diagnosis, the perception and condition of the patient, the distance and cost of travel to a health care facility, the subordinate position of women in household decision-making and the social support that women receive. Barriers at the health care system level include high patient numbers, staff shortages, the duration of the TB diagnostic process as well as the uncaring attitude and poor communication of health care workers. These barriers may apply not only to the submission of the second sample, but to health care access in general. CONCLUSION: Women face multiple barriers in submitting a second sputum sample. These do not operate in isolation but instead compound each other. Although potential solutions to overcome these barriers are recognised, some have yet to be adopted. To improve TB case finding, innovative and community approaches should be adopted more rapidly.

Two methods for setting child-focused tuberculosis care targets.

OBJECTIVE: To allocate resources for household contact investigations, tuberculosis (TB) programs need estimates of the numbers of child contacts requiring care. DESIGN: We developed two methods to estimate annual numbers of child contacts aged 0-14 years requiring evaluation and treatment. Method 1 combines local data using simple formulas. Using publicly available data, Method 2 uses a linear regression model based on Demographic and Health Survey and World Bank data to estimate the number of children per household, then combines these results with case notifications and risk estimates of disease and infection. RESULTS: Applying Method 1 to data from Malawi indicated that every year ~21 000 child contacts require evaluation and ~1900 should be diagnosed with TB. Applying Method 2 to all countries suggested that, globally, 2.41 million (95% uncertainty interval [UI] 2.36-2.46) children aged <5 years, and 5.07 million (95%UI 4.81-5.34) children aged 5-14 years live in households of adult patients with known TB. Of these, 239 014 (95%UI 118 649-478581) and 419 816 (95%UI 140600-1 268805), respectively, will have TB. An additional 848 453 (95%UI 705838-1 017551) and 2660 885 (95%UI 2080517-3 413 189), respectively, will be infected. CONCLUSION: It is feasible to use available data to set programmatic evaluation and treatment targets to improve care for child contacts of patients with TB.

Objectif : Pour allouer des ressources aux recherches de contacts domiciliaires, les programmes de lutte contre la tuberculose (TB) ont besoin d'estimations du nombre d'enfants contacts nécessitant une prise en charge.Schéma : Nous avons élaboré deux méthodes afin d'estimer les nombres annuels d'enfants contacts âgés de 0­14 ans requérant une évaluation et un traitement. La Méthode 1 combine des données locales utilisant des formules simples. En utilisant les données disponibles publiquement, la Méthode 2 se sert d'un modèle de régression linéaire basé sur les données de l'Enquête Démographie et Santé et celles de la Banque Mondiale afin d'estimer le nombre d'enfants dans chaque famille, puis de combiner ces résultats avec ceux de la déclaration des cas et des estimations de risque de maladie et d'infection.Résultats : En appliquant la Méthode 1 aux données du Malawi, nous avons abouti à ce que ~21 000 enfants contacts par an requéraient une évaluation et ~1900 devraient avoir un diagnostic de TB. Appliquer la Méthode 2 à tous les pays a suggéré que, dans le monde, 2,41 millions d'enfants âgés de <5 ans (intervalle d'incertitude [II] à 95% 2,36­2,46 millions) et 5,07 millions (II95% 4,81­5,34 millions) d'enfants âgés de 5­14 ans vivent dans des foyers comprenant un patient adulte atteint de TB chaque année. Parmi eux, 239 014 (II95% 118 649­478 581) et 419 816 (II95% 140 600­1 268 805), respectivement, auront la TB et 848 453 autres enfants (II95% 705838­1017 551) et 2660 885 (II95% 2080 517­3413 189) seront infectés.Conclusion : Il est possible d'utiliser les données disponibles pour établir des objectifs d'évaluation programmatique et de traitement afin d'améliorer la prise en charge des enfants contacts de patients tuberculeux.

Objetivo: Para designar los recursos necesarios para la evaluación de contactos de pacientes con tuberculosis (TB), los programas necesitan estimados de cuántos contactos niños requieren atención.Diseño: Desarrollamos dos métodos de estimar cuántos contactos que tienen 0­14 años requieren evaluación y tratamiento cada año. Método 1 usa información local y fórmulas sencillos. Usando información pública, Método 2 usa un modelo de regresión lineal basado en datos de las Encuestas Demográficas y de Salud y del Banco Mundial para estimar el número de niños en cada domicilio, y luego combina estos resultados con números reportados de casos de TB y con estimados del riesgo de enfermedad e infección con TB.Resultados: Aplicando el Método 1 a datos de Malawi indica que cada año, ~21 000 contactos niños deben ser evaluados y ~1900 deben ser diagnosticados con TB. Aplicando el Método 2 a datos de todos los países del mundo indica que cada año, al nivel mundial, hay 2,41 millón (intervalo de incertidumbre [II] de 95% 2,36­2,46 millón) de niños de edad <5 años, y 5,07 millón (II95% 4,81­5,34 millón) de niños que tienen 5­14 años, quienes viven en domicilios de adultos que se sabe son pacientes con TB. De estos niños, 239 014 (II95% 118649­478 581) y 419816 (II95% 140600­1 268 805), respectivamente, estarán enfermos con TB. Además, 848 453 (II95% 705838­1 017551) y 2 660 885 (II95% 2080 517­3 413189) estarán infectados con TB pero no enfermos.Conclusión: Es factible usar datos disponibles para generar metas programáticas para la evaluación y el tratamiento, con el fin de mejorar la atención a los contactos niños de pacientes con TB.

Burden of disease and risk factors for death among children treated for tuberculosis in Malawi.

SETTING: Tuberculosis (TB) is a leading cause of childhood death. Patient-level data on pediatric TB in Malawi that can be used to guide programmatic interventions are limited. OBJECTIVE: To describe pediatric TB case burden, disease patterns, treatment outcomes, and risk factors for death and poor outcome. DESIGN: We conducted a retrospective cohort study utilizing routine data. Odds ratios (ORs) for factors associated with poor outcome and death were calculated using generalized estimating equations. RESULTS: Children represented 8% (371/4642) of TB diagnoses. The median age was 7 years (interquartile range 2.8-11); 32.8% (113/345) were human immunodeficiency virus (HIV) infected. Of these, 54.0% were on antiretroviral therapy (ART) at the time of anti-tuberculosis treatment (ATT) initiation, 21.2% started ART during ATT, and 24.8% had no documented ART. The treatment success rate was 77.3% (11.2% cured, 66.1% completed treatment), with 22.7% experiencing poor outcomes (9.5% died, 13.2% were lost to follow-up). Being on ART at the time of ATT initiation was associated with increased odds of death compared to beginning ART during treatment (adjusted OR 2.75, 95%CI 1.27-5.96). CONCLUSION: Children represent a small proportion of diagnosed TB cases and experience poor outcomes. Higher odds of death among children already on ART raises concerns over the management of these children. Further discussion of and research into pediatric-specific strategies is required to improve case finding and outcomes.

Scale-up of ART in Malawi has reduced case notification rates in HIV-positive and HIV-negative tuberculosis.

Setting: For 30 years, Malawi has experienced a dual epidemic of human immunodeficiency virus (HIV) infection and tuberculosis (TB) that has recently begun to be attenuated by the scale-up of antiretroviral therapy (ART). Objective: To report on the correlation between ART scale-up and annual national TB case notification rates (CNR) in Malawi, stratified by HIV-positive and HIV-negative status, from 2005 to 2015. Design: A retrospective descriptive ecological study using aggregate data from national reports. Results: From 2005 to 2015, ART was scaled up in Malawi from 28 470 to 618 488 total patients, with population coverage increasing from 2.4% to 52.2%. During this time, annual TB notifications declined by 35%, from 26 344 to 17 104, and the TB CNR per 100 000 population declined by 49%, from 206 to 105. HIV testing uptake increased from 51% to 92%. In known HIV-positive TB patients, the CNR decreased from a high of 1247/100 000 to 710/100 000, a 43% decrease. In known HIV-negative TB patients, the CNR also decreased, from a high of 66/100 000 to 49/100 000, a 26% decrease. Conclusion: TB case notifications have continued to decline in association with ART scale-up, with the decline seen more in HIV-positive than HIV-negative TB. These findings have programmatic implications for national TB control efforts.

Contexte : Pendant 30 ans, le Malawi a connu une double épidémie du virus de l'immunodéficience humaine (VIH) et de la tuberculose (TB) qui s'est atténuée récemment avec l'expansion du traitement antirétroviral (TAR).Objectif : Etablir la corrélation entre l'expansion du TAR et les notifications annuelles de cas de TB, stratifiés en fonction de leur statut VIH positif ou négatif, au Malawi, de 2005 à 2015.Schéma : Une étude rétrospective descriptive écologique reposant sur les données agrégées des rapports nationaux.Résultats : De 2005 à 2015, le Malawi a étendu le TAR de 28 470 à 618 488 patients, avec une couverture de la population passant de 2,4% à 52,2%. Pendant ce temps, les notifications annuelles de TB ont décliné de 35%, de 26 344 à 17 104, et le taux de notification des cas de TB par 100 000 population a décliné de 49%, de 206 à 105. L'utilisation du test VIH a augmenté de 51% à 92%. Chez les patients TB-VIH positifs, les taux de notification des cas ont diminué d'un niveau élevé de 1247/100 000 à 710/100 000 (diminution de 43%). Chez les patients TB-VIH négatifs connus, les taux de notification des cas ont également décru d'un taux élevé de 66/100 000 à 49/100 000 (diminution de 26%).Conclusion : Les notifications de cas de TB ont continué à décliner en association avec l'expansion du TAR, avec un déclin davantage constaté chez les patients TB-VIH positifs que chez les patients TB-VIH négatifs. Ces constatations ont des implications pour les programmes nationaux de lutte contre la TB.

Marco de referencia: Durante 30 años se ha presentado en Malawi una epidemia doble de infección por el virus de la inmunodeficiencia humana (VIH) y tuberculosis (TB), que se ha moderado en tiempos recientes gracias a la ampliación de escala de administración del tratamiento antirretrovírico (TAR).Objetivo: Evaluar la relación entre la ampliación de escala del TAR y la tasa anual nacional de notificación de casos de TB, estratificada por la situación frente al VIH, en Malawi del 2005 al 2015.Método: Fue este un estudio retrospectivo descriptivo ecológico a partir de los datos agregados de notificación a escala nacional.Resultados: Del 2005 al 2015 se amplió la escala de administración del TAR en Malawi de 28 470 a 618 488 casos, con un aumento de la cobertura del 2,4% al 52,2% de la población. Durante este período disminuyó un 35% la notificación anual de TB, de 26 344 a 17 104 casos, y un 49% la tasa de notificación, que pasó de 206 por 100 000 habitantes a 105/100 000. La aceptación de la prueba diagnóstica del VIH aumentó del 51% al 92%. En los pacientes positivos frente al VIH, la tasa de notificación de TB disminuyó de 1 247/100 000 a 710/100 000 (disminución del 43%). En los pacientes negativos frente al VIH, las tasas de notificación de TB también disminuyeron de 66/100 000 a 49/100 000 (disminución del 26%).Conclusión: La notificación de casos de TB ha continuado su disminución en paralelo con la ampliación de escala de administración del TAR; la disminución es mayor en los pacientes positivos frente al VIH que en los pacientes negativos. Estos resultados tienen consecuencias programáticas sobre las iniciativas nacionales de control de la TB.

Decline in adverse outcomes and death in tuberculosis patients in Malawi: association with HIV interventions.

Between 2000 and 2012, the annual numbers of patients treated for tuberculosis (TB) in Malawi declined by 28%, from 28 234 to 20 463. During this time, the proportion of TB patients tested for the human immunodeficiency virus (HIV) increased from 6% to 87%. Most HIV-infected patients received cotrimoxazole preventive therapy, and the proportion receiving antiretroviral therapy increased to 88%. Between 2000 and 2008 there was a significant decline in all adverse outcomes (from 31% to 14%), and particularly in deaths (from 23% to 10%) and loss to follow-up (from 5.2% to 1.9%, P < 0.001). After 2008, there was no decrease in any adverse outcome. Ways to further reduce TB-associated mortality are discussed.

Entre 2000 et 2012, le nombre annuel de patients traités pour tuberculose (TB) au Malawi a décliné de 28%, passant de 28 234 à 20 463. Pendant cette période, la proportion de patients TB testés pour le virus de l'immunodéficience humaine (VIH) a augmenté de 6% à 87%, la majorité des patients infectés par le VIH a bénéficié d'un traitement préventif par cotrimoxazole et la proportion de patients recevant un traitement antirétroviral est passée à 88%. Entre 2000 et 2008, il y a eu un déclin significatif de toutes les évolutions défavorables (de 31% à 14%), en particulier des décès (de 23% à 10%) et des perdus de vue (de 5,2% à 1,9%; P < 0,001). Après 2008, il n'y a plus eu de diminution des évolutions défavorables. L'article discute des manières de poursuivre la réduction de la mortalité associée à la TB.

Del año 2000 al 2012, el número anual de pacientes tratados por tuberculosis (TB) en Malawi disminuyó un 28%, de 28 234 a 20 463. Durante este período, la proporción de pacientes TB en quienes se practicó la prueba diagnóstica de infección por el virus de la inmunodeficiencia humana (VIH) aumentó del 6% al 87%. La mayoría de los pacientes VIH positivo recibió tratamiento preventivo con cotrimoxazol, y la proporción de pacientes que recibía tratamiento antirretrovírico aumentó al 88%. Del 2000 al 2008 se observó una disminución considerable de todos los desenlaces desfavorables (del 31% al 14%) y sobre todo de las muertes (del 23% al 10%) y las pérdidas durante el seguimiento (del 5,2% al 1,9%; P < 0,001). Después del 2008, no se presentó disminución en ninguno de los desenlaces desfavorables. En el artículo se analizan modalidades que permitan disminuir aun más la mortalidad asociada con la TB.

Impact of changing diagnostic criteria for smear-positive tuberculosis: a cohort study in Malawi.

We assessed the impact on measured burden and outcomes of the revised World Health Organization and Malawi guidelines reclassifying people with single (including 'scanty') positive smears as smear-positive pulmonary tuberculosis cases. In a retrospective cohort in rural Malawi, 567 (34%) of 1670 smear-positive episodes were based on single positive smears (including 176 with scanty smears). Mortality rates and the proportion starting treatment were similar in those with two positive smears or single, non-scanty smears. Those with single scanty smears had higher mortality and a lower proportion starting treatment. The reclassification will increase the reported burden substantially, but should improve treatment access.

Decline in national tuberculosis notifications with national scale-up of antiretroviral therapy in Malawi.

From 2000 to 2012, Malawi scaled up antiretroviral therapy (ART) from <3000 to 404 905 persons living with HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome), representing an ART coverage of 40.6% among those living with HIV. During this time, annual tuberculosis (TB) notifications declined by 28%, from 28 234 to 20 463. Percentage declines in annual TB case notifications were as follows: new TB (26%), recurrent TB (40%), new smear-positive pulmonary TB (19%), new smear-negative pulmonary TB (42%), extra-pulmonary TB (19%), HIV-positive TB (30%) and HIV-negative TB (10%). The decline in TB notifications is associated with ART scale-up, supporting its value in controlling TB in high HIV prevalence areas in sub-Saharan Africa.

De 2000 à 2012, le Malawi a étendu la thérapie antirétrovirale (ART) de <3000 à 404 905 personnes vivant avec le VIH/SIDA (virus de l'immunodéficience humaine/syndrome de l'immunodéficience acquise), aboutissant à une couverture par antirétroviraux de 40,6% parmi les personnes vivant avec le VIH. Durant cette période, la déclaration annuelle de la tuberculose (TB) a chuté de 28%, de 28 234 à 20 463. Les pourcentages de diminution annuelle des déclarations de cas de TB se répartissaient comme suit : nouveaux cas de TB (26%), rechute de TB (40%), nouvelle TB pulmonaire à frottis positif (19%), nouvelle TB pulmonaire à frottis négatif (42%), TB extra-pulmonaire (19%), TB chez un patient VIH positif (30%), TB chez un patient VIH négatif (10%). Un déclin dans la déclaration de la TB est associé à une expansion de l'ART, ce qui témoigne de sa valeur dans la lutte contre la TB dans les zones à prévalence élevée de VIH en Afrique sub-saharienne.

Entre el año 2000 y el 2012, se amplió en Malawi la escala de aplicación del tratamiento antirretrovírico (ART), de menos de 3000 a 404 905 personas con infección por el virus de la inmunodeficiencia humana (VIH) y síndrome de inmunodeficiencia adquirida, con lo cual se alcanzó una cobertura de 40,6% de las personas seropositivas. Durante este tiempo, disminuyó un 28% la tasa anual de notificación de tuberculosis (TB), de 28 234 a 20 463 casos. Se observaron las siguientes proporciones en la disminución de la notificación de casos: 26% en casos nuevos de TB, 40% en recaídas de TB, 19% en casos nuevos de TB pulmonar con baciloscopia positiva; 42% en casos nuevos de TB pulmonar con baciloscopia negativa, 19% en casos de TB extrapulmonar, 30% en casos de TB y seropositividad frente al VIH, y 10% en los casos de TB y seronegatividad frente al VIH. La observación de una disminución de la notificación de casos de TB asociada con la ampliación de escala del ART confirma la utilidad de esta estrategia en el control de la TB en las regiones con alta prevalencia de infección por el VIH en África subsahariana.

Surveillance of tuberculosis in Malawian prisons.

SETTING: The Malawi National Tuberculosis Programme (NTP) has collaborated with the Prison Health Services (PHS) on tuberculosis (TB) control in prisons since 1996. Information on case finding and treatment outcomes is routinely collected, but there has not been any recent countrywide review of these prison data. OBJECTIVES: To determine 1) the number of prisoners registered for TB in 2007, 2) TB treatment outcomes in 2006 and 3) training of prison health care staff in all Malawian prisons. DESIGN: Descriptive study involving a review of 2006 and 2007 data collected by the NTP during surveillance in 2008. RESULTS: In 2007, 278 TB patients were registered in Malawian prisons, representing a TB case notification rate of 835 per 100 000 (higher than that in the general population, at 346/100 000). The treatment success rate for new smear-positive TB cases for 2006 was 73%, lower than the national average of 78%. In all, 52 prison health care staff had received 1 week of training in TB management, usually just after starting work in the prison. CONCLUSIONS: TB case notifications in Malawian prisons were higher than in the general population and treatment outcomes less favourable. The NTP and PHS need better collaboration to improve TB control in Malawian prisons.

Timing of antiretroviral therapy and effects on tuberculosis treatment outcomes in HIV-co-infected patients in Malawi.

SETTING: Queen Elizabeth Central Hospital, Blantyre, Malawi. OBJECTIVES: To determine 1) the proportion of human immunodeficiency virus (HIV) infected tuberculosis (TB) patients started on antiretroviral therapy (ART), 2) the timing of ART and 3) the effect of the timing on TB treatment outcomes. DESIGN: A retrospective record review of HIV-infected TB patients registered from January to December 2009. RESULTS: A total of 3376 TB patients were registered, of whom 2665 (79%) were HIV-tested and 2042 (77%) were HIV-infected. A total of 1190 HIV-infected TB patients who were not on ART at the time of starting TB treatment were studied. Of 688 (58%) who started ART, 61% started therapy within 2 months of anti-tuberculosis treatment and 39% started later (≥2 months). Treatment success for patients with TB who started ART within 2 months was higher than for those starting ART later (RR 1.6, 95%CI 1.4-1.8), and death rates were lower (RR 0.25, 95%CI 0.19-0.35). CONCLUSION: Under routine programme conditions in Malawi, a higher proportion of HIV-infected TB patients who started ART did so within 2 months of starting TB treatment, and early ART intervention was associated with better treatment outcomes. This confirms recommendations that co-infected TB patients should start ART early.