Effective Strategy For Detecting Hiv-infected Persons With Tuberculosis In China

Background Tuberculosis (TB) is the most common opportunistic infection and the leading cause of death among HIV seropositive patients (HIV/AIDS). The World Health Organization initiated an interim policy on collaborative TB/HIV activities which included providing HIV testing for all TB patients, intensifying TB screening in HIV/AIDS and providing treatment and care for TB/HIV patients. As one of the high burden countries in TB control in the world, China still remains one of low HIV prevalence overall with pockets of high infection among specific sub-populations and sub-region. The policy needs to adapt to this situation.Objective (1) Improve HIV screening in TB patients with cost-effectiveness. (2) Improve the efficiency of TB symptom screening in HIV/AIDS. (3) Compare anti-TB treatment outcome of TB/HIV patients who come from HIV and TB clinics.Methods (1) A cross-sectional survey of HIV testing for all TB patients was conducted in 333 counties which covered different prevalence of HIV infection during September 1 to December 31 in 2007 and 2008 separately. (2) Four counties with high HIV prevalence implemented a TB symptom questionnaire screening in HIV/AIDS during September 2006 to February 2007. (3) A cohort of anti-TB treatment was established in 14 counties, which enrolled TB patients registered during September 1, 2007 to August 31,2009 and who were followed for half a year. (4) Binary Logistic Regression was used to analyze related-factors of HIV infection, uptake of HIV testing, and mortality during anti-TB treatment.Results(1) There were 45,675 TB cases enrolled with 152 cases known to be HIV-positive. 1,525 cases refused HIV testing.133 new HIV-positive cases were detected from 43,998 cases. The new detection rate of HIV-positive is 0.30% and the prevalence of HIV infection in TB patients is 0.65%. The survey expended $882,096 in total with an average of $10,257 for detecting a new HIV-positive case.(2) If all TB patients were offered HIV testing in counties with cumulatively reporting of more than 200 cases of HIV/AIDS in seven provinces in central China and cumulatively reporting of more than 50 cases of HIV/AIDS in nine provinces in southern and western China, it would cost 16% of expenditure of this survey, and detect 67% new HIV-positive TB cases with an average of $2,403 per one case detection.(3) If all TB patients were offered HIV testing in countries with cumulatively reporting of more than 200 cases of HIV/AIDS and with a TB registry rate of more than 70/100,000 in seven provinces in central China, and cumulatively reporting of more than 50 cases of HIV/AIDS and TB registry rate of more than 70/100,000 in nine provinces in southern and western China, it would cost 9% of expenditure of this survey, and detect 56% new HIV-positive TB cases with an average of $1,648 per one case detection.(4) Compared to the questionnaire using a combination of seven symptoms and sign to screen TB in HIV/AIDS cases, a consistent cough for more than two weeks alone can detect 92% of TB patients, save 25% of the costs for further TB examinations, and the positive predictive value is 12.3%.(5) There were 19,103 pulmonary TB patients in the treatment cohort.925 cases were HIV-positive,72.8% of which came from TB screening in HIV/AIDS and the remaining 27.2% came from HIV testing in TB patients.(6) HIV-positive TB patients who came from HIV testing in TB patients had a higher mortality rate (13.4% vs.7.5%), and a lower treatment success rate (73.2% vs. 76.9%) than those who came from TB screening in HIV/AIDS cases.Conclusion Most HIV-positive TB patients come from TB screening in HIV/AIDS cases and have a better TB treatment outcome and a lower mortality rate relatively. Using a consistent cough more than two weeks to screen TB in HIV/AIDS cases is cost-effective. Offering HIV testing for all TB patients is cost-effective in counties reporting more than 200 cases of HIV/AIDS in central China where former illegal commercial plasma donation is the main route of HIV transmission, and in counties reporting more than 50 cases of HIV/AIDS in other areas of China where drug use and sexual contact are the main route of HIV transmission.