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TB/HIV outreach finding patients in remote South Africa
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A novel tuberculosis and HIV case-finding method effectively detected people with both diseases in a remote area of South Africa, according to researchers.
The community-based approach they used in the impoverished, rural area could be valuable in similar regions, Sheela V. Shenoi, MD, MPH, an assistant professor of medicine and infectious diseases instructor at the Yale University School of Medicine, and colleagues wrote in Open Forum Infectious Diseases.
“We have demonstrated that using a community-based approach to case-finding activities that integrates both TB and HIV screening is feasible and acceptable to community members in rural settings,” they wrote.
The researchers tested the method in the medical subdistrict of Msinga, KwaZulu–Natal, a roughly 2,000-km2 area that is home to about 180,000 native Zulu. The area is South Africa’s poorest medical subdistrict, and many residents do not have electricity or clean water. Additionally, the area’s rugged terrain and shortage of paved roads make it hard to reach.
The researchers employed a community-based intensive case-finding (CBICF) team that included health educators, nurses and HIV counselors who attended area events. From March 2010 to June 2012, the team visited municipal events, home-based care events, prisons and other sites to share TB and HIV information with residents and elicit volunteer testing for the diseases.
Altogether, they visited 322 sites or events, where 5,615 people were screened for TB. Of those, 5,128 (91.3%) also underwent rapid HIV testing. .
Municipal events yielded the most participants, with 37.7% of the total. Another 21.5% were screened at home-based care events; 21% at pension pay points, where they received social stipends; 6.3% at secondary schools; 5.6% at taxi stations ; 4.5% at health fairs; and 3.4% at prisons. Of those screened, 69% were women, and the median age for patients was 41 years.
In all, 2,049 (36.4%) participants reported TB symptoms. Although they all tried, just 1,033 (50.4%) were able to submit sputum for testing, and the CBICF team found 41 (4%) cases of TB.
In all, 510 (9.9%) people tested positive for HIV or were already known to have it. Of those who submitted sputum for TB testing, 116 (11.2%) also had HIV. Among the 41 TB cases the CBICF team found, five (12.2%) were coinfected with HIV.
That differed noticeably with the 64% TB/HIV coinfection rate found in Msinga by the national Directly Observed Therapy Short-Course (DOTS) program, which tracks TB patients to help them complete their courses of medication (P < .001). Most DOTS data come from medical facilities, the researchers said.
Similarly, the CBICF team detected no HIV cases among participants with drug-resistant TB, compared with 80% to 90% HIV coinfection among patients registered by DOTS.
The researchers suggested that coinfected peoples’ reaction to illness onset, compared with that of people with TB only, may explain both the data disparity and the prevalence of TB in the community setting.
In patients with TB only, disease progression is likely slower, and they are less often prompted to quickly seek treatment at a medical facility, the researchers said. Those people may act as a community TB reservoir feeding a continuing epidemic.
In contrast, those with both TB and HIV have more rapid progression and are more likely to quickly seek treatment at a facility, where the DOTS data are gathered. Those patients also shorten their period of infectiousness and avoid contributing to the TB prevalence found in the community. – by Joe Green
Disclosure: The authors report no relevant financial disclosures.
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