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

12th World AIDS Conference

Abstracts 22154-22158 293

L453* /22154 How likely are TB patients to be accurately
diagnosed in urban health centres in Lusaka,
Zambia?
Peter Godfrey-Faussett1, Joseph Kamanga2, H. Kaunda2, A. Kambashi2,
M. Van Cleef3, V. Tihon2. 1GTB WHO 1211 Geneva 27, Zambart Project,
London School of Hygiene & Tropical Medicine, London, UK; 2Zambart Project,
University Teachings Hospital, Lusaka, Zambia, 3Royal Tropical Institute,
Amsterdam, Netherlands
Background: The HIV epidemic has led to a dramatic rise in the incidence of
tuberculosis (TB). This is particularly severe in urban settings where government
health services are now stretched to the limit. In order to limit the impact of
HIV on TB control, we have established a health systems research project that
will build capacity for operational research and explore the bottlenecks through
which a patient has to pass from their first symptom to their final cure. This study
examined the efficiency of the diagnostic process followed in two large urban
health centres (UHC), one of which had its own microscopy service and one in
which patients had to be referred to the hospital for sputum microscopy.
Methods: Prospective observational study of patients with a cough at the
clinical interview, as they left the UHC, at the hospital and at the laboratory.
Results: 514/821 (66%) patients were classified by the researchers as TB
suspects (cough for more than 3 weeks or haemoptysis). Only 146 of these 514
(28%) finally had a sputum microscopy result available of which 15% were positive. In both UHC's around 65% of suspects were referred for sputum examination
but poor communication in the clinical room meant that 10% did not understand
or had forgotten by the time they left. In the UHC with a laboratory 64%, of
those who understood that they were meant to, brought sputum samples within
one month and 96% of these samples had results available. In the other UHC,
31% brought samples to the hospital and results were only identifiable in 78% of
these. Both UHC's referred about 30% of patients who were not classified as TB
suspects by the researchers and these patients contributed 24% of all sputum
samples received at the laboratory.
Conclusions: The research has prompted the UHC to upgrade its laboratory in
order to examine its own patients' samples. A trial of an intervention, transporting
the sputum and not asking the patient to take it, is underway at another UHC.
Clinicians involved in the analysis workshop are encouraging others to select
patients for microscopy more efficiently.
|22155] Characteristics of the new cases of tuberculosis (TB)
- after the implementation of universal TB prophylaxis
Jose Joaquin Portu, J. Agud, M. Aldamiz-Etxebarria, C. Ayensa, S. Barroso,
M.J. Almaraz, M. Fernandez. Hospital Txagorritxu, Victoria-Gasteiz, Spain
Objectives: To determine the characteristics of the new cases of Tuberculosis
(TB) as an indicative disease of AIDS.
Design: Retrospective study.
Methods: TB is the most usual indicative disease of AIDS in our community
and the most prevalent in its evolution. 52% of AIDS patients suffered from TB just
before starting a universal prophylaxis programme in 1995. The characteristics of
the TB cases treated between 1995 and 1997 are analysed below.
Results: Percentages of TB as indicative disease of AIDS: 33% (n = 20) in
1995; 24% (n = 16) in 1996 and 59% (n = 23) in 1997.
Prevalence of TB in HIV patients: 33 cases in 1995; 23 in 1996 and 23 in 1997.
Origin of TB patients and its relation with prophylaxis:
(1) No Prophylaxis (95%): 39% (n = 23) came from prison; 17% (n = 10) were
patients who were aware of been infected with HIV infection, in spite of this they
did not attend their check-ups; 15% (n = 9) came from a Therapeutic Community
for negleted people; 12% (n = 7) had not accepted prophylaxis; 7% (n = 4) were
unfinished prophylaxis of which (n = 3) were abandoned; 3% (n = 2) led to the
diagnosis of HIV infection and 1.7% (n = 1) was controlled without prophylaxis.
(2) Fulfilled Prophylaxis (5%): 5% had fulfilled the prophylaxis correctly.
Conclusions: TB is still the most prevalent opportunistic infection in our community. It affects patients who hardly had any contact with Health Services, who
had not received prophylaxis.
We should think of new ways of creating effective prophylaxis programmes that
could reach unaccesible patients.
22156 Profile of HIV patients and compliance to primary
prophylaxis therapy to tuberculosis (TB) in an out-patient
clinic in Belo Horizonte, Brazil, July 95 June 97
Unai Tupinambas1, D.B. Greco2, S.S. Moll2, L.M. Diniz2, L.F. Xavier2,
M.M. Menezes2, M. Diniz2. ' Dona Cecilia St 55-501 Serra Belo Horizonte
30220-070 MG: 2Federal University of Minas Gerais Belo Horizonte, Brazil
Objectives: To evaluate the characteristics of HIV patients and compliance to
prophylaxis for TB (INH).
Methodology: From 87 HIV+ patients who were started on primary TB prophylaxis (July 95 to June 97) in an out-patient clinic the following data was evaluated

from 82 of them (five were lost to follow up): gender, age, CD4 level, PPD (5UT),
use of antiretrovirals and compliance to TB prophylaxis (Abandon of treatment
was considered if patient failed to return for medication after two months). Fiftyfour (65.9%) were male and 28 (34.1%) female, with 59.8% of them with ages
ranging from 16 to 35 years. HIV risk factors for male: homo-bisexual: 63%;
heterosexual 35%; IDU 2%. Risk factors for female: 85.7% acquired HIV through
heterosexual contact, 7.1% were IDU; 7.1% through blood transfusion and 3.6%

(1 patient) through materno-fetal transmission. From 60 patients with PPD. or =
5 mm, 80% had more than 200 CD4+ cells/mm3. Two were not tested with PPD
and 2 had a PPD <- 5 mm. From 18 patients anergic to PPD, 55.5% had more
than 200 CD4+ cells/mm3 and 8 had a history of recent contact (- 6 months) with
a patient with pulmonary TB. Antiretrovirals were being used by 49 individuals
(59.8%). Of the 33 (40.2%) who complied with the prophylatic treatment, 18
(54.5%) were also on antiretrovirals. Among the 49 (59.8%) non-compliers, 30
(61.2%) were on antiretroviral therapy.
Conclusions: The rate of non-compliance for TB prophylaxis was very high,
especially if we consider that these patients were being followed at a well established specialty clinic, with all drugs (including antiretrovirals) being provided
free of charge. It must be noted that the majority of the non-compliers were also
in use of antiretrovirals. The reasons for non-compliance is multifatorial and the
importance of TB prophylaxis will need to be more emphasized both to the health
personnel and to the patients to help change this picture.
221571 Mycobacterial species distribution in isolates from
Brazilian HIV-infected patients and its consequences on
clinical approach
Monica Jacques Demoaraes1, M.C.R. Ramos2, A.R.C. Calusni2,
M.C.V. Villares2, M.R. Resende2, V.M.L. Lima2. 'R. Frei Manuel Da
Ressurreigao 15613073-021 Campinas; 2University of Campinas - UNICAMPM
Campinas, SP, Brazil
Background: Management of mycobacterial infections is species specific.
Species identification is however laborious, and because of its high costs and
the historically high incidence of M. tuberculosis in Brazil and other developing
countries, the current practice in these countries has been to diagnose tuberculosis (TB) based on positive smears. After the AIDS epidemic many studies
have shown an increase in the relative incidence of other mycobacteria and many
times even a clear preponderance of the latter. Nonetheless most studies were
done in industrialized countries, where the incidence of TB is much lower than
in developing countries. The objective of the current study was to determine the
species distribution of mycobacterial isolates from various body sites recovered
from HIV-infected patients during 1996 in Campinas University Clinic, Brazil, and
to try some clinical correlates.
Methods: Samples were grown in conventional (Lowestein-Jensen) and new
(BACTEC) media and hybridization with DNA probes was used for the identification. Clinical data was reviewed.
Results: 100 samples from 58 patients grew mycobacteria, from which 57
(57%) were M. tuberculosis and 43 (43%), M. avium. After multiple specimens
of the same patient were excluded, we verified that 34 patients (59.6%) were
infected with M. tuberculosis and 24 (41.4%) with M. avium. While 71% and
78% of the sputum and cerebral spinal fluid isolates were M. tuberculosis, most
(80%) mycobacteria isolated from blood were M. avium. All the M. avium infected
patients were put on ineffective therapy, and 50% died, against 23% in the M.
tuberculosis group.
Conclusions: Our data show that the smear-based approach to mycobacterial
infections is inadequate to HIV-infected patients in Campinas, Brazil. Furthermore, when mycobacteria is isolated from blood, combined therapy for TB and
MAC should be initiated, pending identification. These findings cannot be readily
applied to other developing countries, but suggest that also in TB-prevalent areas,
the high frequency of M. avium justify the introduction of identification methods in
the routine for the HIV-infected patients group.
22158 Tuberculosis in persons infected with HIV disease in
southern Vietnam
Patricia Kloser 2, D.L. Pham2, V.N. Le3, P.K. Correll'. UMDNJ/New Jersey
Medical School, Newark, NJ; 2695 Cardinal Hill Lane, Powell, Ohio, USA; 3Pham
Ngoc Thach TB/Lung Center, Hochiminh City, Vietnam ('USA)
Issue: The diagnosis and treatment of tuberculosis, through a program adopted in
1986, had reduced tuberculosis rates in Southern Vietnam. Concomitant infection
with HIV has complicated treatment and created a dramatic rise in tuberculosis
rates (23% between 1995 and 1996).
Project: Data from the National Tuberculosis Control Program (NTCP) was
examined for the purposes of identifying characteristics of high-risk persons,
diagnosing and reporting new and recurrent tuberculosis infection, and providing
effective treatment. Client data from the Pham Ngoc Thach Tuberculosis and
Lung Disease Center in Ho Chi Minh City (HCMC) was examined for changes
in tuberculosis rates since the first case of HIV was detected in HCMC in 1990
(average increase of 7%). Pham Ngoc Thach is the central coordinating center
for the NTCP in South Vietnam and services approximately 28.5 million people.
Other factors complicating tuberculosis control were examined, including lack of
treatment compliance, homelessness (3%), resistance to common antituberculotic medications and a declining cure rate (currently 75%, down from 870% in
1985). Mortality rates of HIV infection with tuberculosis were also studied.
Results: Pulmonary and extrapulmonary tuberculosis rates have continued to

increase steadily. Tuberculosis is more common in males (57%) than females.
Poor medication compliance and an increase in drug resistant strains appear to
be related to drug failure and relapse. Tuberculosis, secondary to HIV infection,
has a fatality rate of 80% within three weeks of diagnosis.
Lessons Learned: Pulmonary and extrapulmonary tuberculosis incidence
continues to increase despite creased surveillance and aggressive treatment programs. Tuberculosis in the presence of HIV infection leads to increased mortality.