Integration of HIV testing in tuberculosis drug resistance surveillance in Kazakhstan and Kenya.

In Kenya and Kazakhstan, integration of human immunodeficiency virus (HIV) testing results into the routine surveillance of multidrug-resistant tuberculosis (MDR-TB) proved feasible and useful. The integration process improved overall data quality and data validation capacity, and integrated data are a useful addition to routine cohort and treatment outcome data. Besides their importance for individual patient care, they provide trends on the association of MDR-TB and HIV in the routine programme setting. They also form a useful epidemiological basis for more specific studies, such as on nosocomial outbreaks. Whether the system itself is sensitive enough to monitor possible outbreaks needs further investigation.

Public-private mix for control of tuberculosis and TB-HIV in Nairobi, Kenya: outcomes, opportunities and obstacles.

SETTING: Nairobi, the capital of Kenya. OBJECTIVE: To promote standardised tuberculosis (TB) care by private health providers and links with the public sector. DESIGN AND METHODS: A description of the results of interventions aimed at engaging private health providers in TB care and control in Nairobi. Participating providers are supported to provide TB care that conforms to national guidelines. The standard surveillance tools are used for programme monitoring and evaluation. RESULTS: By the end of 2006, 26 of 46 (57%) private hospitals and nursing homes were engaged. TB cases reported by private providers increased from 469 in 2002 to 1740 in 2006. The treatment success rate for smear-positive pulmonary TB treated by private providers ranged from 76% to 85% between 2002 and 2005. Of the 1740 TB patients notified by the private sector in 2006, 732 (42%) were tested for human immunodeficiency virus (HIV), of whom 372 (51%) were positive. Of the 372 HIV-positive TB patients, 227 (61%) were provided with cotrimoxazole preventive treatment (CPT) and 136 (37%) with antiretroviral treatment (ART). CONCLUSION: Private providers can be engaged to provide TB-HIV care conforming to national norms. The challenges include providing diagnostics, CPT and ART and the capacity to train and supervise these providers.

Planning for PPM-DOTS implementation in urban slums in Kenya: knowledge, attitude and practices of private health care providers in Kibera slum, Nairobi.

SETTING: Kibera, the largest slum in Nairobi, Kenya. OBJECTIVE: To determine the tuberculosis (TB) knowledge, attitude and practices (KAP) of private health care providers (PHCPs) to identify their training needs and willingness to participate in a National Leprosy and Tuberculosis Control Programme (NLTP) guided TB control effort in the slum. DESIGN AND METHODOLOGY: A cross-sectional survey. The KAP of PHCPs was assessed using an interviewer administered questionnaire. RESULTS: Of 75 PHCPs interviewed, the majority (96.0%) were paramedics; 51 (77.1%) did not consider sputum smear microscopy crucial in patients presenting with prolonged cough or when a chest X-ray was suggestive of TB; of 29 (38.7%) who indicated familiarity with the drugs used in TB treatment, 20 (58.5%) would have chosen the NLTP-recommended regimens for the treatment of the various types of TB; 16 (21.3%) PHCPs indicated that they treated TB, six (37.5%) of whom were not familiar with anti-tuberculosis drug regimens. All the PHCPs referred TB suspects to the public sector for diagnosis. CONCLUSION: This study reveals a significant gap in TB knowledge among the PHCPs in Kibera slum. However, given appropriate training and supervision, there is potential for public-private mix for DOTS implementation in this setting.

Isolation of multidrug-resistant tuberculosis strains in patients from private and public health care facilities in Nairobi, Kenya.

SETTING: Health care facilities in Nairobi, Kenya. OBJECTIVE: To document the presence of multidrug-resistant tuberculosis (MDR-TB) strains in patients from Nairobi between September 1999 and October 2001. DESIGN: Descriptive study. RESULTS: Of the 983 referred patients who submitted sputum for culture and drug susceptibility testing (DST), 59% were males. Two hundred and nine (21.3%) patients had a positive culture, of whom 15.2% had a request for DST against isoniazid, rifampicin, streptomycin and ethambutol. Of these, 65 (43.6%) had an isolate resistant to one or more drugs, while 17 (11.4%) had MDR-TB. Ten (59.0%) cases were referred from public health care facilities while seven (41%) were from the private sector. Sixteen isolates were resistant to all four drugs. All MDR-TB cases but one were from Nairobi. CONCLUSION: The emergence of MDR-TB in Nairobi is a cause for concern. An outbreak would be catastrophic, creating not only increased morbidity and mortality but also a tremendous strain on already limited health care resources. Lack of policies for the treatment and management of MDR-TB and the unavailability of appropriate diagnostic facilities may increase its spread. Efforts to prevent outbreaks of MDR-TB should be emphasised.

HIV sero-prevalence among tuberculosis patients in Kenya.

OBJECTIVE: To determine HIV seroprevalence among tuberculosis patients and the burden of HIV attributable tuberculosis among notified patients in Kenya. DESIGN: A cross-sectional anonymous unlinked HIV seroprevalence survey. SETTING: Tuberculosis diagnostic clinics of the National Leprosy Tuberculosis Programme in 19 districts. SUBJECTS: One thousand nine hundred and fifty-two newly notified tuberculosis patients. INTERVENTIONS: Selection and registration of eligible subjects followed by obtaining 5 ml of full blood for haemoglobin testing and separation of serum for HIV testing by ELISA. MAIN OUTCOME MEASURES: HIV seroprevalence per district and burden of HIV attributable tuberculosis among tuberculosis patients. RESULTS: A total of 1,952 eligible patients were enrolled. The weighted seroprevalence in the sample was 40.7% (range 11.8-79.6% per district). The seroprevalence was significantly higher among females and patients with sputum-smear negative tuberculosis. Chronic diarrhoea, female sex, oral thrush and a negative sputum were independent risk factors for HIV infection. The Odds ratio for HIV infection in female tuberculosis patients aged 15-44 years, was 5.6 (95% CI 4.5-6.9) compared with ante-natal clinic attenders. The population attributable risk was 0.22 in 1994. CONCLUSION: The HIV epidemic has had a profound impact on the tuberculosis epidemic in Kenya and explains about 41% of the 94.5% increase of registered patients in the period 1990-1994 and 20% of all registered patients in 1994. Repetition of the survey with inclusion of a more representative control group from the general population may provide a more accurate estimation of the burden of HIV attributable tuberculosis.

PIP: This cross-sectional survey determined HIV seroprevalence among tuberculosis patients and the burden of HIV attributable tuberculosis among notified patients in Kenya. Data were collected from 1952 patients. The information gathered included demographic data, date of treatment initiation, type of patient, type of tuberculosis, sputum-smear results, and data concerning the signs and symptoms related to tuberculosis and HIV disease. Findings demonstrated that the weighted seroprevalence in the study sample was 40.7% (range, 11.8-79.6% per district), which is significantly higher in females and patients with sputum-smear negative tuberculosis. Chronic diarrhea, female sex, oral thrush, and negative sputum were independent risk factors for HIV infection. The odds ratio for HIV infection in female tuberculosis patients aged 15-44 years was 5.6 compared with antenatal clinic attenders.