Implementation and Operational Research: Feasibility of Using Tuberculin Skin Test Screening for Initiation of 36-Month Isoniazid Preventive Therapy in HIV-Infected Patients in Resource-Constrained Settings.

INTRODUCTION: The tuberculin skin test (TST) can be used to identify HIV-infected people who would benefit the most from long-term isoniazid preventive therapy (IPT). However, in resource-constrained settings, implementation of the TST can be challenging. The objectives of this study were to assess the feasibility of implementing the TST for IPT initiation and to estimate the proportion of TST-positive incidence among HIV-positive patients in 2 high tuberculosis and HIV burden settings. METHODS: Two prospective observational cohort studies were conducted under programmatic conditions in Mathare, an urban slum of Nairobi, Kenya, and in rural Shiselweni, Swaziland. HIV-positive adults with negative tuberculosis symptomatic screening underwent the TST. Those testing positive were started on 36-month IPT. RESULTS: Of 897 and 1021 patients screened in Mathare and Shiselweni, 550 and 696, respectively, were included. Median age was 38 years, 67.7% were female, and 86.8% were on antiretroviral therapy. Among TST-eligible participants, 88.0% (491/558) and 81.8% (694/848) accepted TST and 74.2% (414/558) and 77.1% (654/858) returned for test reading in Mathare and Shiselweni, respectively. The TST was positive in 49.8% (95% confidence interval: 44.9 to 54.6) in Mathare and 33.2% (95% confidence interval: 29.6 to 36.8) in Shiselweni. The 36-month IPT was accepted by 96.1% (198/206) patients in Mathare and 99.5% (216/217) in Shiselweni. IPT implementation at the clinics was managed with no additional staff or extra space. CONCLUSION: Implementing the TST for IPT initiation was feasible and acceptable in both urban and rural resource-constrained settings. This strategy allows patients who can benefit the most to receive long-term IPT and avoids unnecessarily treating a significant number of patients who do not stand to benefit.

Targeting vulnerable households in urban Burkina Faso: effectiveness of geographical criteria but not of proxy-means testing.

The 2007/2008 food prices hike has increased the interest in social safety nets programmes to fight food insecurity. Targeting the most in need is central to achieve effectiveness of such interventions. In 2009 in Ouagadougou, Burkina Faso, a food voucher (FV) programme targeted the 25 000 most vulnerable households (8.3% of the population). Targeting used a two-stage process: first geographical selection of poorest districts (∼90 000 households); then, in those districts, identification of the most vulnerable households according to a proxy-means test (PMT). Targeted households were entitled to receive FV for 1 year. A first survey was conducted at the beginning of the FV distribution on a representative sample of 2273 households drawn from the poorest districts. One year later a second survey, conducted on a subsample of same households (n = 901), identified those who actually received FV (beneficiary). The performance of the whole process was assessed against household food expenditure, used as the reference measure for vulnerability with a cut-off point of 1513 FCFA (corresponding to the 8.3th percentile of the distribution of expenditure). The 'normalized share of transfers going to vulnerable households' (NSTVH), i.e. proportion of FVs allocated to households below the cut-point, was the main criteria of judgement. Almost twice as many FV were allocated to vulnerable households as compared with a theoretical random distribution all over Ouagadougou (NSTVH = 1.85). When considering the sole targeted districts the NSTVH was only 0.84 (i.e. no more effective than a random distribution), meaning that the geographical stage was effective to select vulnerable districts while the PMT did not perform well to identify the most vulnerable households in those districts. Results could have been improved if only targeted households had received FV (NSTVH = 2.61 and 1.18 for the whole Ouagadougou and targeted districts, respectively). Improved targeting procedures or alternate targeting instruments are needed.