Of the 33.2 million persons infected with human immunodeficiency virus (HIV), one-third are estimated to also be infected with Mycobacterium tuberculosis. In 2008, there were an estimated 1.4 million new cases of tuberculosis (TB) among persons with HIV infection, and TB accounted for 26% of AIDS-related deaths. The relative risk of TB among HIV-infected persons, compared with that among HIV-uninfected persons, ranges from 20- and 37-fold, depending on the state of the HIV epidemic. In 2008, 1.4 million patients with TB were tested globally for HIV, and 81 countries tested more than half of their patients with TB for HIV. Only 4% of all persons infected with HIV were screened for TB in the same year. Decentralization of HIV treatment services and strengthening of its integration with TB services are essential. Use of the highly decentralized TB services as an entry point to rapidly expand access to antiretroviral therapy and methods for prevention of HIV infection must be pursued aggressively.

HIV/AIDS, tuberculosis, and malaria are 3 major global public health threats and cause substantial morbidity, mortality, negative socioeconomic impact, and human suffering. Despite the significant increase in financial support and recent progress in addressing these 3 diseases, important obstacles and unmet priorities remain. Disease-specific interventions have had a considerable impact on improving health systems. However, despite considerable investment, weak health systems, inadequate human resources, and poor laboratory infrastructure continue to be major obstacles to expanding health services. Health system strengthening should be addressed in an integrated approach that includes HIV-, tuberculosis-, and malaria-specific interventions. Investment in strategic information and public health laboratory network capacity strengthening are key actions to expand services to successfully address those diseases in heavily impacted countries.

AIDS 2010, 24 (suppl 5):S57-S65

Human immunodeficiency virus (HIV) infection drives tuberculosis (TB) incidence, and in some African countries, 80% of persons with TB have HIV infection. By the end of 2008, an estimated 33.2 million persons were infected with HIV, and in 2007, there were 2.7 million new HIV infections and 2 million HIV infection-related deaths. During the same year, there were 1.37 million (15%) cases of TB and HIV coinfection, resulting in 456,000 deaths. Prevention of TB requires prevention interventions for both HIV infection and TB, including HIV counseling and testing, disclosure and partner testing, behavior modification, earlier antiretroviral therapy, and the "Three I's for HIV/TB": isoniazid preventive treatment, intensified case finding, and infection control for TB. Managers of HIV programs should work with their colleagues in the TB field and the community to ensure that persons infected with HIV have access to the "Three I's for HIV/TB" as part of universal access to high-quality comprehensive prevention, care, and treatment of HIV infection and TB.

ObjectiveThe aim of this study was to describe treatment outcomes for multi-drug resistant tuberculosis (MDR-TB) outpatients on a standardized regimen in Nepal.MethodologyData on pulmonary MDR-TB patients enrolled for treatment in the Green Light Committee-approved National Programme between 15 September 2005 and 15 September 2006 were studied. Standardized regimen was used (8Z-Km-Ofx-Eto-Cs/16Z-Ofx-Eto-Cs) for a maximum of 32 months and follow-up was by smear and culture. Drug susceptibility testing (DST) results were not used to modify the treatment regimen. MDR-TB therapy was delivered in outpatient facilities for the whole course of treatment. Multivariable analysis was used to explain bacteriological cure as a function of sex, age, initial body weight, history of previous treatment and the region of report.Principal FindingsIn the first 12-months, 175 laboratory-confirmed MDR-TB cases (62% males) had outcomes reported. Most cases had failed a Category 2 first-line regimen (87%) or a Category 1 regimen (6%), 2% were previously untreated contacts of MDR-TB cases and 5% were unspecified. Cure was reported among 70% of patients (range 38%–93% by Region), 8% died, 5% failed treatment, and 17% defaulted. Unfavorable outcomes were not correlated to the number of resistant drugs at baseline DST. Cases who died had a lower mean body weight than those surviving (40.3 kg vs 47.2 kg, p<0.05). Default was significantly higher in two regions [Eastern OR = 6.2; 95%CL2.0-18.9; Far West OR = 5.0; 95%CL1.0-24.3]. At logistic regression, cure was inversely associated with body weight <36 kg [Adj.OR = 0.1; 95%CL0.0-0.3; ref. 55–75 kg] and treatment in the Eastern region [Adj.OR = 0.1; 95%CL0.0-0.4; ref. Central region].ConclusionsThe implementation of an ambulatory-based treatment programme for MDR-TB based on a fully standardized regimen can yield high cure rates even in resource-limited settings. The determinants of unfavorable outcome should be investigated thoroughly to maximize likelihood of successful treatment.