Prevalence of nontuberculous mycobacteria (NTM) disease is poorly documented in countries with high prevalence of tuberculosis (TB). We describe prevalence, risk factors, and TB program implications for NTM isolates and disease in Cambodia. A prospective cohort of 1,183 patients with presumptive TB underwent epidemiologic, clinical, radiologic, and microbiologic evaluation, including >12-months of follow-up for patients with NTM isolates. Prevalence of NTM isolates was 10.8% and of disease was 0.9%; 217 (18.3%) patients had TB. Of 197 smear-positive patients, 171 (86.8%) had TB confirmed (167 by culture and 4 by Xpert MTB/RIF assay only) and 11 (5.6%) had NTM isolates. HIV infection and past TB were independently associated with having NTM isolates. Improved detection of NTM isolates in Cambodia might require more systematic use of mycobacterial culture and the use of Xpert MTB/RIF to confirm smear-positive TB cases, especially in patients with HIV infection or a history of TB.

Objective: To describe the implementation and utilization of the Xpert ® MTB/RIF (Xpert) assay to diagnose tuberculosis (TB) among people living with the human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS, PLHA) in Cambodia. Design: Following the rollout of Xpert, an evaluation was conducted in four provinces of Cambodia from March to December 2012 to determine the utilization, performance, and turnaround time (TAT) of Xpert among PLHA. Data were collected from paper-based patient registers. Results: Of 497 PLHA with a positive TB symptom screen, 357 (72%) were tested with smear microscopy, and 250 (50%) with Xpert; 25 (10%) PLHA tested with Xpert were positive for TB and none were rifampicin-resistant. The utilization of Xpert increased from 23% to 75%, with a median TAT of 1 day. Across districts, utilization ranged from zero to 85%, while the TAT ranged from zero to 22 days. Conclusion: While early data show increasing utilization of Xpert for PLHA with a positive symptom screen, most patients underwent smear microscopy as an initial diagnostic test. Training delays and challenges associated with specimen referral may have contributed to variability in Xpert uptake and TAT, particularly for sites without onsite Xpert testing. Enhanced programmatic support, particularly for specimen referral and results reporting, may facilitate appropriate utilization.

Although utilization of Xpert was low, it may have contributed to an increase in evaluations for possible MDR-TB and a decline in empiric treatment for PLHIV when available as POC.

Background: Cambodia has a high burden of Tuberculosis (TB) with an incidence rate of 326 per 100,000 population in 2018 and rapidly increasing rates of Diabetes Mellitus (DM) with prevalence rate 9.6% in 2016. The introduction of the first national guidelines for the management of TB/DM co-morbidity in 2014 has resulted in the introduction of coordinated service delivery. Objective: This study aimed to assess the performance and the results of bidirectional TB/DM screening, diagnosis of co-morbidity, and enrollment in treatment in 7 health operational districts in 5 provinces in Cambodia. Methods: The retrospective study reviewed patient records of 6,463 DM patients and 8,403 TB patients who received treatment between July 2016 and February 2019 in 7 referral hospitals and 113 health centers. Results: Forty percent of DM patients were screened for TB, and 55% of TB patients were screened for DM. Of the screened DM patients, 4.6% were diagnosed with TB. Of screened TB patients, 3.7% were diagnosed with DM. All DM patients diagnosed with TB were enrolled in TB treatment and 95% of TB patients diagnosed with DM began receiving treatment for DM. Conclusion: This is the first study examining TB/DM co-morbidity and coordinated service delivery in Cambodia.The gaps in the performance of bidirectional screening suggest areas for further intervention. To increase the rate of bidirectional screening, provider compliance with standards needs to be improved by strengthening providers competencies. Strengthened data collection and reporting systems will also contribute to increasing provider accountability. Secondly, the current structure of TB and DM service delivery with TB services only available from the public sector and public DM services only available at the referral level creates a challenging environment for effective referrals and coordinated care and should be reconsidered. In addition to improved coordination between the public and private sectors, expansion of public DM services to health centers and to the community level warrants exploration. Finally, the increased focus needs to be given to addressing the high levels of pre-diabetes.Cambodia has a limited window of opportunity to build capacity and develop systems to effectively manage TB/DM co-morbidity.

Tuberculosis and HIV/AIDS have synergistic health impacts in terms of disease development and progression. Therefore, collaborative TB and HIV/AIDS activities are a logical health systems response. However, the establishment of these activities presents a challenge for countries that have strong vertical disease programs that differ in their implementation philosophies. Here, we review the process by which TB/HIV collaboration was established in Cambodia. A cycle of overlapping and mutually reinforcing initiatives – local research; piloted implementation with multiple options; and several rounds of policy formulation guided by a cross-functional Technical Working Group – was used to drive nationwide introduction of a full set of TB/HIV collaborative activities. Senior Ministry of Health officials and partner organizations brought early attention to TB/HIV. Both national programs implemented initial screening and testing interventions, even in the absence of a detailed, overarching framework. The use of multiple options for HIV testing identified which programmatic options worked best, and early implementation and pilots determined what unanswered questions required further research. Local conduct of this research – on co-treatment timing and TB symptom screening – speeded adoption of the results into policy guidance, and clarified the relative roles of the two programs. Roll-out is continuing, and results for a variety of key indicators, including screening PLHIV for TB, and testing TB patients for HIV, are at 70-80% and climbing. This experience in Cambodia illustrates the influence of health research on policy, and demonstrates that clear policy guidance, the pursuit of incremental advances, and the use of different approaches to generate evidence can overcome structural barriers to change and bring direct benefits to patients.