Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

136 Abstracts 13250-13254

12th World AIDS Conference

region (10.1%), North America (5.3%), and Europe (4.2%). A higher proportion
of black non-Hispanics born in the Caribbean (19.4%), Africa (16.3%), and North
America (8.9%) had TB-AIDS than had other racial groups. Black non-Hispanics
born in Africa (prevalence ratio [PR] = 4.5, 95% confidence interval [CI] 2.3-9.1)
or the Caribbean (PR = 3.6, 95% Cl 2.1-6.0), were more likely to be reported with
TB than white non-Hispanics with AIDS born in the same regions. Asians born
in the Asia/Pacific region were more than 4 times as likely to have TB-AIDS as
Asians born in North America (12.7% vs 3.0%).
Conclusion: Persons with AIDS who live in the United States but were born
in other regions of the world are more likely to be reported with TB than are
persons born in North America. This pattern may reflect TB prevalence in region
of birth and delayed access to preventive treatment for certain racial groups. This
findings emphasize the importance of early HIV testing, testing for TB infection,
monitoring for TB disease, and treatment to prevent or delay the HIV-related
immunosuppression associated with the risk for active TB.
S13250 Characteristics of adult HIV-infected female tuberculosis
S patients, US, 1993-1996
Amy B. Curtis, E. McCray. CDC 1600 Clifton Rd. N.E. MSE-10 Atlanta Georgia
30333, USA
Background: Beginning in 1993, information on HIV status at diagnosis of tuberculosis (TB) has been collected in the US national TB surveillance system. The
characteristics of women with TB and HIV co-infection are described below.
Methods: Data from US National TB surveillance for 1993-1996 was analyzed.
Verified female TB cases, 20 years and greater, with HIV status reported as either
(-) or (+) were included in the analyses. California and Rhode Island reported no
HIV information and thus are excluded from all analyses.
Results: HIV results were reported for 8263 of 23588 (35%) adult female
TB patients. 29% (2421/8263) were reported as HIV(+). HIV(+) women were
younger (37 years vs 45 years) and more likely to be black (72% vs 40%) than
HIV(-) women. The percent (73%) of women with pulmonary TB did not differ
between HIV(+) and (-); however, HIV(+) women were twice as likely to have
both pulmonary and extra-pulmonary disease than HIV(-) women (11% vs 5%).
Among women with pulmonary disease, HIV(+) women were less likely to have
an abnormal chest radiograph (CXR) (87% vs 96%). Of those with abnormal
CXRs, 16% of HIV(+) and 32% of HIV(-) women had cavitary disease. HIV(+)
women were both more likely to be dead at the time of TB diagnosis (6% vs 1%)
and to die while on TB therapy (31% vs 5%) than HIV(-) women. 6% of HIV(+)
women and 2% of HIV(-) women were resistant to at least INH and rifampin.
HIV(+) women were 5 times (10% vs 2%) as likely to be resistant to rifampin only
compared to HIV(-) women.
Conclusion: Reporting of HIV results among women in the National TB surveillance system remains low. However, among those with reported HIV status, HIV
prevalence is high. HIV(+) women are less likely to have abnormal CXRs and
cavitary disease, making diagnosis more difficult. Furthermore, drug resistance
to the two most effective TB medications among HIV(+) women is greater than
among HIV(-) women, complicating treatment.
S13251 Feasibility of screening and preventive therapy for
tuberculosis among intravenous drug users: The SerT/TB
study
Enrico Girardi. Centro Riferimento AIDS IRCCS L.Spallanzani via Portuense 292
Rome, Italy
Objective: To evaluate feasibility and operational problems of a program of
preventive therapy for tuberculosis among intravenous drug users (IVDU) cared
for in public Drug Treatment Centers (DTC) in Italy. To provide data for a
cost/effectiveness analysis of this intervention.
Design: Prospective, observational, multicenter study
Methods: All IVDUs consecutively observed in 10 DTC in Italy were enrolled
in this study. According to national guidelines, PPD testing and HIV testing was
offered to all enrolled subjects. Evaluation for active tuberculosis and presence
of contraindications to preventive therapy was offered to all PPD+ individuals
Results: A first analysis was conducted on 1237 individuals enrolled between
February I and October 30, 1997. 257 (20%) were HIV+ and 47 (3.8%) refused
HIV testing. Overall 1071 individuals (86.5%) underwent PPD testing and returned for skin test reading. Acceptance of PPD was similar among HIV+ and
HIV-individuals. Prevalence of tuberculin positivity was 6.3% among HIV+ (PPD
> 5 mm) and 11.7% among HIV-(PPD _ 10 mm). Of HIV+ potential candidates to
preventive therapy, half did not complete screening for active TB and contraindications to INH and 25% had contraindications to INH. or factors that determined
increased risk of toxicity to INH (mainly chronic liver diseases) and none of the
remaining individuals accepted preventive therapy.
Conclusions: In spite of the high rate of acceptance of PPD screening among
HIV+ IVDUs, difficulties in completing clinical evaluation before starting INH, high
prevalence of chronic liver disease and low acceptance of preventive therapy may
greatly diminish effectiveness of preventive therapy programs in this population.

S13252 Which HIV infected populations should be considered
"high risk" for tuberculosis (TB)?
M. Anita Barryl11, J.E. Gunn22, D. Brett22, H.M. Carvalho22. 1010
Massachusetts Avenue Boston MA 02118; 2Boston Public Health Commision
Boston MA, USA
Background: Despite limited data, preventive therapy (PT) has been recommended for HIV+ anergic persons from populations believed to be at high risk for
TB infection.
Methods: We identified 245 anergic HIV+ persons without a prior +PPD &
evaluated their rate of progression to TB disease. All subjects had 3 skin tests;
anergy was defined as a response <5 mm to PPD, <2 mm to candida, & <2
mm, to either tetanus toxoid or mumps. Records were reviewed for demographics, clinical data, & outcomes including death, TB disease, or nontuberculous
mycobacteria (NTM).
Results: Outcome data were available for 236 (96%) with a mean follow-up
time of 32 months. Cohort demographics were 74% male, 60% non-white, &
45% <35 years old. Baseline clinical features included 47% with CD4 counts
<200 cell/mm3, 40% on antiretroviral therapy, 16% with a prior opportunistic
infection. TB risk factors were 76% IDU, 41% incarceration, 28% homeless, &
29% from endemic countries. 199 (84%) did not complete PT. PT related side
effects developed in 31, including 18 with elevated serum transaminases & 7 with
rash. Clinical outcomes were as follows:

Death
NTM cases (rate per 1000 person years)
TB cases (rate per 1000 person years)

97 (41%)
15(24)
1 (1.6)

Only 1 individual, a foreign born male who was anergic in 1992, developed
culture confirmed pulmonary TB in 1994. His TB risk factors were IDU, homelessness, incarceration & no PT. Using published rates of progression (Selwyn,
1989), the estimated prevalence of TB infection in 199 subjects without adequate
PT was 4%.
Conclusion: In our cohort with a 16% PT completion rate, the incidence of
TB over an average 32 month follow-up was only 1.6 per 1000 person years.
We conclude that even in "high risk" populations, anergy testing failed to identify
persons likely to progress to TB disease. Decisions regarding PT should be based
on PPD testing alone, both in individuals & populations. Unless a group has been
demonstrated to have a high rate of TB infection, the benefits of PT in HIV+
anergic person are unlikely to outweigh its risks.
S13253 Characteristics of HIV-positive health care workers
reported with tuberculosis in the United States, 1993 to
1996
Yvette Davis', E. McCray2, I.M. Onorato2. 1CDC 1600 Clifton Road Mailstop
E10 NCHSTP DTBE Atlanta Georgia 30333 USA; 2Centers For Disease Control
& Prevention Atlanta GA, USA
Background: Reports of tuberculosis (TB) cases in the United States (US),
including information on HIV-status, are submitted annually to the CDC. In January 1993, expanded TB surveillance was implemented in the US to improve
monitoring and to target groups at risk of disease. HCWs were included because
of numerous reports of nosocomial outbreaks in urban hospitals, many of which
involved multidrug-resistant strains of Mycobacterium tuberculosis.
Methods: We analyzed surveillance data from the US for TB cases reported
from 1993-1996, and compared demographic and clinical characteristics of HIVpositive (HIV[+]) health care workers (HCWs) to HIV[+] non-health care workers
(n-HCWs).
Results: During the period from 1993 to 1996, 1,596 TB cases were reported
among HCWs and 31,652 TB cases were reported among n-HCWs who were 20
to 49 years of age at diagnosis. Information on HIV-status was missing for a large
proportion of HCWs (60.0%) and n-HCWs (53.9%). Among the TB cases with
known HIV-status, 24.8% of HCWs and 41.5% of n-HCWs were HIV[+]. HIV[+]
HCWs with TB were more likely to be female (33.5% vs 22.1%); white (22.8% vs
15.3%); and foreign-born (26.6% vs 14.9%), compared to HIV[+] n-HCWs. HIV[+]
HCWs were less likely to have a previous diagnosis of TB (3.2% vs 4.8%), and
more likely to be diagnosed with extra pulmonary TB only (24.7% vs 18.2%). In
New York City, HIV[+] HCWs were more likely to be resistant to isoniazid and
rifampin when compared to HIV[+] n-HCWs (24.3% vs 8.9%), whereas in the rest
of the country, drug resistance was low among both groups (1.9 vs 3.0).
Conclusions: These data suggest that there are some differences between
HIV-positive HCWs with TB and HIV-positive n-HCWs with TB with regard to
demographics and clinical disease. Further studies are needed to determine risk
factors for occupational transmission of TB among HIV-positive HCWs.
13254 Drug resistant pulmonary tuberculosis in a cohort of
Southern African gold miners with a high prevalence of
HIV infection
Pamela Sonnenberg1, J. Murray2, S.C.P. Shearer3, P. Godfrey-Faussett4.
1Epedimiology Research Unit, Johannesburg; 2National Centre for Occupational
Health, Johannesburg; 3Goldfield of South Africa; Johannesburg,, South Africa;
4Zambart Project & LSHTM, Lusaka,, Zambia
Background: The South African gold mining industry has a high incidence of
pulmonary tuberculosis (TB) and a high prevalence of HIV infection in its largely