1. Surveillance for TB in HIV Care and Treatment Settings (CTS)
Lisa J. Nelson, MD MPH MS
TB/HIV Team Leader
International Research and Programs Branch
Division of TB Elimination, CDC

2. Timeline of TB/HIV Surveillance
HIV infection
TB diagnosed
Timeline

3. Rationale for TB Surveillance in CTS
TB is important cause of morbidity and mortality
Care and treatment programs should have measurable effect
TB may be well-suited to measure trends over time
Possibility of studying other interventions

4. Antiretroviral Therapy (ART)
Study
Location
# Enrolled
TB Reduction
Comment
Brodt,
AIDS 1997
Germany
1003 NS
Only men w/ CD4<200
Lederberger, JAMA 1999
Switz.
2140
18% (-31, -3)
Girardi,
AIDS 2000
Italy
2160
HR 0.16
(0.03, 0.74)
Jones,
IJTLD 2000
U.S.
14,457
RR 0.2
(0.1, .05)
Santoro-Lopes, CID 2002
Brazil
255
(0.04, 1.13)
Excluded prior dx of TB
Badri,
Lancet 2002
South Africa
264
ARR 0.2
(0.09, 0.38)
Benefit at CD4<350

5. Possibility of Evaluating Other Interventions
Intensified TB Case Finding (ICF)
Isoniazid Preventive Therapy (IPT)
Cotrimoxazole Preventive Therapy (CPT)
Antiretroviral therapy (ART)

6. Considerations for TB Surveillance in CTS
Case definition of TB
What data elements to collect
Smear status
Disease status (pulmonary vs. extrapulmonary)
CD4 at TB diagnosis
Previous history of TB or IPT
TB treatment outcome

7. TB Assessment for Patients in Chronic HIV Care
Suspect TB
Suspect TB:
Cough > 2 weeks, persistent fever, unexplained weight loss, severe undernutrition, suspicious nodes, sweats
New Sm+ or
Tx plan from
District: treat for TB
TB suspected
on prior visit
Active TB
Suspect TB
On TB tx
Send 3 sputums
Refer if not producing
sputum or nodes
No SSx,
Not on tx
or prophylaxis
No SSx
or on prophylaxis
No suspicion of TB
WHO/CDS/IMAI/2004.2

8. How/Where to Conduct? At HIV diagnosis
Clinical settings (hospital, OPD)
Program settings (VCT, PMTCT, prior to IPT)
In HIV care and treatment settings (CTS)
Clinics providing ARV
Home-based care

9. Methodological and Logistical Issues
Care interventions may increase TB rates
ART may cause immune reconstitution phenomena
Intensified TB case finding (vs. passive case detection)
May require complicated analysis
Need to ensure TB cases are notified to NTP
Fewer ethical issues

10. Use of TB Surveillance Systems
Include additional variables
Source of referral
Prior use of IPT
Use of CPT, ART
Need to have referral mechanism in place

11. Conclusions TB surveillance in CTS more complicated
Must be considered as care and treatment programs scale up
Consensus needed on methodology and approach