The Zambian prison health system has historically lacked the resources and capacity needed to implement rigorous screening, diagnosis and treatment measures for communicable diseases among inmates. 18–20 The Enhancing TB Services in ZambianPrisons project demonstrates that – despite the multiple challenges of operating in the prisons of a lower middle-income country – a range of interventions can effectively enhance screening for tuberculosis and case detection for both tuberculosis and HIV. Although mass screening is resource-intensive and probably only possible on a periodic basis, we were able to test 3929 inmates and 1308 encampment residents in a 9-month period. In low-resource settings – where routine screening may otherwise be lacking – mass screening has value. The project also demonstrated the potential of more systems-oriented activities to address the chronic shortages of human
Methods Ethics Statement
The protocol was approved by the biomedical research ethics committee of the University of Zambia (001-03-11), and the institutional review board of the University of Alabama at Birmingham (F101014011), United States of America. Both institutions waived informed consent for participation in screening activities since they were considered standard of care. Special attention was paid to the vulnerable nature of this population in the context of provider initiated HIV testing services. All HIV counseling was conducted by experienced psycho-social counselors in a private one-on-one setting. Inmates had the chance to opt-out of HIV testing, or to choose not to receive the results if they did test. No inmate was required to carry any form or indication of results that may later identify him or her as HIV positive.
defined by an induration size of 5 mm or more in the HIV-infected, after ruling out active disease. Despite possible limitations in sensitivity and specificity, TST remains a useful primary screening test for the diag- nosis of latent TB infection among HIV-infected persons, with up to 24-fold difference in risk of subse- quent active TB disease between test-positive and test-negative subjects in a previous study. 83 Newer blood tests (interferon-g release assays) based on T-cell response to MTB–specific antigens are not influ- enced by previous BCG vaccination and have several operational advantages, for example no return visit required, operator independence and no boosting effect from repeated testing. 82 While data on the disease-predicting values of interferon-g release assays among HIV-infected persons remain scanty, a meta-analysis suggested rather similar performance between TST and interferon-g release assay, at least in low- and intermediate-income countries. 84 Currently available data on the efficacy of preventive treatment in HIV-infected patients are primarily based on TST. Notwithstanding these gaps in existing data, interferon-g release assays are gaining increasing acceptance in high-income countries, particularly for screening of BCG-vaccinated subjects and as com- pared with TST, their sensitivity might also be affected to a lesser extent in patients with compromised immunity. 82
GeneXpert®MTB/RIF testing: A spot sputum specimen must be collected under supervision from an inmate presenting symptoms of TB and then sent for GeneXpert® testing. The laboratory request form must be completed fully and specify that this is a pre-treatment specimen. The results must be followed up with the laboratory within 24-48 hours. GeneXpert® MTB/RIF is particularly useful as a screening tool for TB in HIV-positive inmates where most patients initiated on ART lack the classical symptoms of TB resulting in missed diagnosis. The test must not replace symptom screening but can be used in combination with symptoms and chest X-ray to increase sensitivity of testing.
Clinical screening algorithms: In 2007, WHO International Expert Committee issued new guidelines to improve the diagnosis of TB in HIV infected individuals. It was advocated that screening for TB should not only include asking questions about a combination of symptoms rather than only about chronic cough. A recent meta-analysis depicts that the presence of any one of current cough, fever, night sweats or weight loss was best performing rule. The reversal of chronic cough with current cough is the only change to existing practice as a screening question and the addition of other symptoms to ideal screening.
If initial serologic tests confirm an HIV infection, repeat testing is not indicated.
If initial serologic tests are HIV EIA negative and there is no indication for confirmation of infection by viral RNA detection, the interval prior to retesting is 3−6 months.
* Testing for evidence of HIV infection using serologic methods may be medically appropriate in situations where there is a risk of exposure to HIV. However, in the absence of documented AIDS defining or HIV-associated disease, an HIV-associated sign or symptom, or documented exposure to a known HIV- infected source, the testing is considered by Medicare to be screening and thus is not covered by
policy of testing with patient notiﬁcation as a routine part of prenatal care 2,8 .
Despite the extremely encouraging evidence showing decreased transmission with ZDV treat- ment in pregnant women, screening for HIV in this population remains inadequate. Women who obtain prenatal care still complete their pregnan- cies without being screened. Suggestions in the literature for universal screening of all pregnant women began as early as 1991 9 . Before that time, the recommendations had been to screen only patients with risk factors 9 . Many reasons have been cited for the lack of universal screening, including limitations of provider time, lack of up- to-date education, and inequity of care 10,11 . Both prospective and retrospective studies have shown improvements in the rates of testing with protocols for universal testing 2,12,13,14 . The future holds a multitude of possibilities for improving screening. State legislation is one area in which improvements have already been made. When the state of Connecticut instituted mandatory HIV screening for all neonates if antepartum testing had not been done, the frequency of testing increased from 39.1% to 91.4% 15 . Other methods include standard protocols being created in prenatal care ofﬁces, updates in education to those providing prenatal care, and positioning of staff reminders such as posters in ofﬁces.
The sites were responsible for the selection of children. Selection criteria for children included the following. There were a signed informed consent and documented legal guardianship in case parental consent could not be obtained.
The age was between 1 month and 12 years. (One month was chosen as the cutoff because of the lower sensitivity of DNA PCR for children less than 1 month old [25, 30, 46]. Twelve years was an arbitrary cutoff.) Antiretroviral therapy was not yet started, and there was a previously unmet need for HIV testing, because of medical reasons or a request of the legal guardian. The project tried as much as possible to attend to the unmet need without creating additional demand for HIV testing. All selected children were accepted for testing, except when the number exceeded the capacity of the phlebotomy team. In such case, the staff of the site was asked to reduce the number. The research team was blind to the serostatus of all children. No attempts were made to apply a clinical case defi- nition or to obtain medical information.
Rapid HIV assays. The advent of HIV prophylactic treatments following an occupational blood or body fluid exposure, as well as a need to be able to provide HIV results to patients in a clinic or emergency room or during labor and delivery, set the stage for manufacturers to develop rapid HIV assays. These card-based as- says have gone through the same first through third generations as the main screening tests. Tests have been developed for whole blood, serum, and oral fluid. The OraQuick method is a third- generation HIV antibody assay which is FDA waived and has also been approved for home testing (http://www.fda.gov/Biologics BloodVaccines/BloodBloodProducts/ApprovedProducts /PremarketApprovalsPMAs/ucm311895.htm). Overall, the rapid tests perform well.
In all three trials, participants received regular risk-reduction counseling, condoms, medication-adherence counseling, and testing for sexually transmitted infections with treatment as indicated. No serious
toxicities were reported in any of the trials; however, in the first 1– 2 months on medication, nausea and vomiting were more common in those receiving treatment compared with those receiving placebo.
Conclusions: Clinicians in TB-endemic regions should maintain a high index of suspicion for hepatic TB in patients presenting with hepatomegaly, fever, respiratory symptoms, and elevated liver enzymes. The most sensitive imaging modality is a CT scan, while the most specific diagnostic modality is a liver biopsy with nucleic acid testing of liver tissue samples. Upon diagnosis, 4-drug anti-TB therapy should promptly be initiated. HIV co-infected patients may have more complex cases and should be closely monitored for complications.
Ideally, these tests would be used in serial or parallel testing strategies that would allow for screening and confirmation of initially reactive specimens in a single clinic visit (1).
New HIV RT that can use whole-blood specimens have been available for several years; however, little data exist about their performance in rural, resource-poor settings. To address this question, an effective method for assuring the quality of whole- blood RT results is needed. Whole blood dried on filter paper (dried blood spots [DBS]) has been applied in large-scale HIV surveillance studies for well over a decade (13). DBS can easily be collected at the same time as the whole-blood specimens for the rapid HIV assays and could be used to validate the on-site
The amplification primers developed here also add versatil- ity to this system, because the same first-round PCR product can be used with one of two nested second-round PCR primer pairs to generate either a pool of recombinant virus or clones of recombinant virus (pJM31⌬GPRT and pJM20⌬GPRT primer pairs [Table 1]). This may facilitate laboratory testing algorithms for speeding diagnostic testing involving clonal analyses. For example, a pool of recombinant virus can be rapidly generated by cotransfection of PCR products with pJM31⌬GPRT. If a screening phenotype of the pool (or bulk genotype of the PCR products) suggests minimal or no resis- tance or if other indications suggest that minority mutants be sought, then another aliquot of the same first-round PCR products can be amplified with the alternate second-round primers to permit molecular cloning into pJM20⌬GPRT. This would allow specimens without easily detectable dominant re- sistance to be triaged for a clonal analysis.
ities among patients with HIV-TB co-infection even before they become clinically apparent   .
In addition, the decrease in prices for ultrasound equipment makes this imaging modality easily available and a cost effective screening and diagnostic tool especially in resource constrained countries.
Abdominal sonographic findings of TB in patients with advanced immune deficiency include: mesenteric hypo-echoic lymphadenopathy   - ascites   , multiple splenic hypo-echoic nodules and thickened matted bowel loops. Some studies however have found ascites to be more common in HIV nega- tive patients   . Evidence of TB elsewhere, like in this study may provide circumstantial evidence in favor of a diagnosis.
25. Lawn SD, Harries AD, Meintjes G, et al. Reducing deaths from tuberculosis in antiretroviral treatment programmes in sub-Saharan Africa. AIDS. 2012;26(17).
26. The use of lateral flow urine lipoarabinomannan assay (LF-LAM) for the diagnosis and screening of active tuberculosis in people living with HIV Policy update https://www.who.int/tb/publications/use-of-lf-lam-tb-hiv/en/
In high burden and resource-limited countries like Ethiopia, integrating health services on TB and HIV has
paramount importance in order to increase the effective- ness of the diagnosis and to improve the management approaches . Considering this, the WHO introduced collaborative strategies to control HIV associated TB and Ethiopia is one of the countries exercising this program as part of the health care system . The Centers for Disease Control (CDC) program in Ethiopia (opened in 2001) is providing guidance and technical support towards TB-HIV co-infection and MDR-TB services. As a result, large improvements have been achieved in HIV testing, ART provision and diagnostic potential. Studying the prevalence of TB-HIV co-infection is important for programmatic changes or further improvements on the existing programs.
Worldwide, tuberculosis (TB) infects one third of the population. One of its main drivers has been the epidemic of humanimmunodeficiencyvirus (HIV) infection. On a biological and clinical level, it has been shown that HIV and TB reinforce each other. HIV increases the risk of TB disease by up to 100-fold. On the other hand, active TB is associated with an increased risk of opportunistic infections and rise in HIV viral load. 1,2 Their coexistence in an individual also produces atypical features of TB complicating management. 2. The prognosis has dramatically improved for HIV infected patients with or without TB, 3 following the availability of highly active antiretroviral therapy (HAART). Nevertheless, its concurrent use with anti- tuberculosis treatment may be complicated by immune reconstitution inflammatory syndrome (IRIS) and complex drug-drug interactions.
4. Interaction between TB and HIV in co-infection
TB is the most common serious opportunistic infection in HIV positive patients and is a manifestation of AIDS in more than 50% of cases in developing countries. TB shorten the survival of patients affected with HIV infection and may accelerate the progression of HIV infection to AIDS and, hence is a cause of death in one third of people with AIDS worldwide (UNAIDS/WHO, 2003). Higher mortality observed in co-infected individuals is due to progression into AIDS rather TB due to the fact that M. tuberculosis increases viral replication. On the other hand, the HIV epidemic has the potential to worsen the TB situation as has happened in certain African countries.
BACKGROUND: This study was done to study the prevalence of Tuberculosis (TB) in patients suffering from humanimmunodeficiencyvirus (HIV) infection. The study was conducted at the Cytopathology laboratory, Pathology Department, P. D. U. Government Medical College, Rajkot (Gujarat, India).MATERIALS AND METHODS: In the present study, total 300 patients with HIV have been considered. In our institute most of the patients are directly referred by clinical departments like TB & Chest disease, Medicine, Surgery etc. Fine Needle Aspiration Cytology (FNAC) if simple was done after taking consent of the patient or their relatives. After aspiration, At least two smears are prepared. Few smears are immediately fixed with methanol while few other smears are air-dried and fixed. Then fixed smear is stained with H&E and dry smear is stained with Zeihl-Neelson and Giemsa stain.RESULTS: In our study many cases of tuberculosis have been noted amongst the patients who are suffering from HIV and it confirms that patient suffering from HIV is more prone to opportunistic infections like TB.CONCLUSION: Tuberculous lymphadenitis (38%) was found to be the most common lesion affecting HIV positive patients followed by chronic nonspecific lymphadenitis (29.33%).The overall rate of AFB positivity in Tuberculous lymphadenitis was found to be 46.49%.The most common cytomorphological feature in Tuberculous lymphadenitis was epitheloid granulomas with caseous necrosis.