Geographic information system-based screening for TB, HIV, and syphilis (GIS-THIS): a cross-sectional study.

OBJECTIVE: To determine the feasibility and case detection rate of a geographic information systems (GIS)-based integrated community screening strategy for tuberculosis, syphilis, and human immunodeficiency virus (HIV). DESIGN: Prospective cross-sectional study of all participants presenting to geographic hot spot screenings in Wake County, North Carolina. METHODS: The residences of tuberculosis, HIV, and syphilis cases incident between 1/1/05-12/31/07 were mapped. Areas with high densities of all 3 diseases were designated "hot spots." Combined screening for tuberculosis, HIV, and syphilis were conducted at the hot spots; participants with positive tests were referred to the health department. RESULTS AND CONCLUSIONS: Participants (N = 247) reported high-risk characteristics: 67% previously incarcerated, 40% had lived in a homeless shelter, and 29% had a history of crack cocaine use. However, 34% reported never having been tested for HIV, and 41% did not recall prior tuberculin skin testing. Screening identified 3% (8/240) of participants with HIV infection, 1% (3/239) with untreated syphilis, and 15% (36/234) with latent tuberculosis infection. Of the eight persons with HIV, one was newly diagnosed and co-infected with latent tuberculosis; he was treated for latent TB and linked to an HIV provider. Two other HIV-positive persons had fallen out of care, and as a result of the study were linked back into HIV clinics. Of 27 persons with latent tuberculosis offered therapy, nine initiated and three completed treatment. GIS-based screening can effectively penetrate populations with high disease burden and poor healthcare access. Linkage to care remains challenging and will require creative interventions to impact morbidity.

Predictors of latent tuberculosis treatment initiation and completion at a U.S. public health clinic: a prospective cohort study.

BACKGROUND: Treatment of latent tuberculosis infection (LTBI) is a key component in U.S. tuberculosis control, assisted by recent improvements in LTBI diagnostics and therapeutic regimens. Effectiveness of LTBI therapy, however, is limited by patients' willingness to both initiate and complete treatment. We aimed to evaluate the demographic, medical, behavioral, attitude-based, and geographic factors associated with LTBI treatment initiation and completion of persons presenting with LTBI to a public health tuberculosis clinic. METHODS: Data for this prospective cohort study were collected from structured patient interviews, self-administered questionnaires, clinic intake forms, and U.S. census data. All adults (>17 years) who met CDC guidelines for LTBI treatment between January 11, 2008 and May 6, 2009 at Wake County Health and Human Services Tuberculosis Clinic in Raleigh, North Carolina were included in the study. In addition to traditional social and behavioral factors, a three-level medical risk variable (low, moderate, high), based on risk factors for both progression to and transmission of active tuberculosis, was included for analysis. Clinic distance and neighborhood poverty level, based on percent residents living below poverty level in a person's zip code, were also analyzed. Variables with a significance level <0.10 by univariate analysis were included in log binomial models with backward elimination. Models were used to estimate risk ratios for two primary outcomes: (1) LTBI therapy initiation (picking up one month's medication) and (2) therapy completion (picking up nine months INH therapy or four months rifampin monthly). RESULTS: 496 persons completed medical interviews and questionnaires addressing social factors and attitudes toward LTBI treatment. 26% persons initiated LTBI therapy and 53% of those initiating completed therapy. Treatment initiation predictors included: a non-employment reason for screening (RR 1.6, 95% CI 1.0-2.5), close contact to an infectious TB case (RR 2.5, 95% CI 1.8-3.6), regular primary care(RR 1.4, 95% CI 1.0-2.0), and history of incarceration (RR 1.7, 95% CI 1.0-2.8). Persons in the "high" risk category for progression/transmission of TB disease had higher likelihood of treatment initiation (p < 0.01), but not completion, than those with lower risk. CONCLUSIONS: Investment in social support and access to regular primary care may lead to increased LTBI therapy adherence in high-risk populations.

Tuberculosis knowledge, attitudes, and beliefs among North Carolinians at increased risk of infection.

OBJECTIVE: The purpose of this study was to capture and describe knowledge, attitudes, and beliefs about tuberculosis (TB) among persons at high risk for TB infection. METHODS: We conducted 11 focus groups in 3 different populations at high risk for TB infection: Spanish-speaking immigrants, homeless shelter residents, and persons attending a drug/alcohol rehabilitation center. A standardized list of open-ended questions was used to guide discussion. Using grounded theory, transcripts of the focus group sessions were reviewed by 4 independent reviewers to identify emergent themes. FINDINGS: Participants (N = 52) generally understood that TB is an infectious disease that frequently affects the lungs and can be fatal if untreated. They also knew that a skin test can be used to diagnose TB. However, participants frequently had incorrect beliefs regarding the cause, transmission, and treatment of TB. Many participants thought that TB is transmitted in the same fashion as other infectious diseases such as human immunodeficiency virus or aquired immune deficiency syndrome (HIV/AIDS). A general sentiment of fear and aversion toward persons ill with TB was expressed. LIMITATIONS: Focus groups were a convenience sample and subjects were not necessarily representative of the underlying populations. CONCLUSIONS: Tuberculosis knowledge among high-risk populations is suboptimal, and false beliefs regarding transmission and treatment were common in this study. Knowledge regarding transmission of other infectious diseases such as HIV/AIDS was frequently translated into incorrect knowledge regarding TB. Stigma continues to be a barrier to TB diagnosis and treatment.

Why condoms break

Condom breakage is discussed based on research conducted by Family Health International. Breaks have been attributed to manufacturing defects, poor storage conditions, and most particularly incorrect use. The studies in the US and 8 other African, Latin American, and Asian countries showed that a relatively small number of couples was responsible for a large proportion of breakages. Quality control was assured in these studies for quality, transport, and storage conditions. The manufacturer of the silicone lubricated condoms was the same. Participants were all experienced users, and were given instructions on correct use. 1 condom/single act of intercourse was requested. Follow up interviews were conducted with those couples who broke >20 percent of the condoms tested. 4 factors accounted for breakages: 1) use of oil based lubricants, which has been shown to be harmful to latex; 2) intensity or extended duration of intercourse between 10-30 minutes; 3) reuse; and 4) putting on condoms incorrectly. Oil lubricants were used in several cases because of complaints of lack of lubrication as reported in Kenya. Availability of suitable lubricants was also a problem as reported in Mexico. Petroleum jelly and hair tonic, both oil based, were some of the products used incorrectly. It was suggested that this was a common practice. In the US, Sri Lanka, and Mexico there were reports of longer duration coitus. In Mexico and Jamaica, reuse of condoms was considered quite common, perhaps because of a misunderstanding that 1 period of use could mean several ejaculations. Men in Kenya and Mexico reported unrolling and stretching condoms and putting them on like a sock. Inspecting condoms for holes because of poor quality was also a common practice. 1 participant unrolled the condom only over the tip of the penis. Suggested improvements were better instructions such as: to specify a readily available non-oil-based lubricant, such as saliva, because of nonavailability of water-based lubricants in many countries. Where water-based lubricants are available, brands should be specified. Even in the US, 66 percent of respondents considered baby oil and 33 percent considered massage oil or petroleum jelly acceptable for use with latex condoms