Expanding HIV surveillance to include TB patients in resource-limited settings with a generalized epidemic.

Screening of antenatal clinic attendees is central to monitoring the human immunodeficiency virus (HIV) epidemic. However, recent evidence suggests that declining fertility rates are affecting the reliability of antenatal clinic surveys as the epidemic matures. Population-based HIV surveys, while ideal, are resource-intensive, necessitating newer, cost-effective approaches. Unlinked anonymous testing for HIV in sputum of tuberculosis (TB) patients serves as reliable proxy for estimating the burden of symptomatic HIV disease and is a potential adjunct to current surveillance efforts. Unlinked anonymous testing for HIV surveillance in KwaZulu-Natal, South Africa, the epicentre of the global epidemic, is justified, as data from the largest urban TB referral clinic indicate that only 22% of TB patients uptake voluntary HIV testing.