The performance and yield of tuberculosis testing algorithms using microscopy, chest x-ray, and Xpert MTB/RIF.

SETTING: The introduction of Xpert MTB/RIF (Xpert) and renewed interest in chest x-ray (CXR) for tuberculosis testing has provided additional choices to the smear-based diagnostic algorithms used by TB programs previously. More programmatic data is needed to better understand the implications of possible approaches. OBJECTIVE: We sought to evaluate how different testing algorithms using microscopy, Xpert and CXR impacted the number of people detected with TB in a district hospital in Nepal. DESIGN: Consecutively recruited patients with TB-related symptoms were offered smear microscopy, CXR and Xpert. We tested six hypothetical algorithms and compared yield, bacteriologically positive (Bac+) cases missed, and tests conducted. RESULTS: Among 929 patients, Bac+ prevalence was 17.3% (n = 161). Smear microscopy detected 121 (75.2% of Bac+). Depending on the radiologists' interpretation of CXR, Xpert testing could be reduced by (31%-60%). Smear microscopy reduced Xpert cartridge need slightly, but increased the overall diagnostic tests performed. CONCLUSION: Xpert detected a large proportion of Bac+ TB cases missed by microscopy. CXR was useful in greatly reducing the number of diagnostic tests needed even among presumptive TB patients. Loose CXR readings should be used to identify more people for TB testing. More analysis of costs and standardized CXR reading should be considered.

Vulnerability of wives of Nepalese labor migrants to HIV infection: Integrating quantitative and qualitative evidence.

HIV risk is determined by the interaction between social and individual risk factors, but information about such factors among Nepalese women is not yet understood. Therefore, to assess the risk factors and vulnerability of the wives of Nepalese labor migrants to HIV infection, the authors conducted a mixed-methods study in which a descriptive qualitative study was embedded within a case-control study. Two hundred twenty-four wives of labor migrants were interviewed in the case-control study, and two focus group discussions (n = 8 and 9) were conducted in the qualitative study. The authors found that illiteracy, low socio-economic status, and gender inequality contributed to poor knowledge and poor sexual negotiation among the wives of labor migrants and increased their risk of HIV through unprotected sex. Among male labor migrants, illiteracy, low socio-economic status, migration to India before marriage, and alcohol consumption contributed to liaisons with female sex workers, increasing the risk of HIV to the men and their wives through unprotected sex. Both labor migrants and their wives feared disclosure of positive HIV status due to HIV stigma and thus were less likely to be tested for HIV. HIV prevention programs should consider the interaction among these risk factors when targeting labor migrants and their wives.

Social and behavioural risk factors for HIV infection among the wives of labour migrants in Nepal.

Summary Labour migration has increased the risk of HIV infection among the wives of labour migrants in Nepal. We conducted a matched case-control study to identify the social and behavioural factors for HIV infection among the wives of labour migrants in Nepal. We interviewed 112 wives of labour migrants diagnosed with HIV (cases) and 112 wives of labour migrants testing negative for HIV (controls) and used logistic regression analysis to assess independent factors associated with HIV infection. Literacy status was the only one woman-related social factor associated with HIV infection. Meanwhile literacy status, age when going abroad for the first time and country of migration were the husband-related social factors and alcohol consumption, living alone abroad and having an unpaid partner abroad were the husband-related behavioural factors associated with HIV infection in the wives. Given the husband-related social and behavioural factors are mostly determining the risk of HIV infection in the wives in our study, prevention efforts must incorporate behaviour change approaches targeting specifically to labour migrants and also to their wives.