Faculty Bibliography

Setting: Urban, non-governmental HIV outpatient clinic in Mombasa, Kenya. Objective: To report outcomes and assess feasibility of serial clinical screening for active TB among adults enrolled in outpatient HIV care in a resource-limited setting. Design: Longitudinal analysis of screening conducted during routine clinic visits of HIV-infected Kenyan adults. The provider-initiated screen included TB symptom assessment and targeted physical exam. Participants with >1 symptom/sign were to submit sputum for microscopy and undergo chest radiography. Results: Over 33 months, 4,854 HIV-infected outpatients were serially screened for active TB at a median interval of 3 months. Treatment for active TB was started in 127 (2.6%). Of those 127, 77 (60.6%) were diagnosed based on first screen, and 50 (39.4%) were diagnosed thereafter. Among those 50 diagnosed upon subsequent screens, 28 (56%) were identified in association with positive screens, suggesting that 22% (28 of 127) of TB diagnoses could be attributed to the serial screening protocol. Conclusion: Provider-initiated serial clinical screening during routine visits of HIV-infected outpatients continued to prompt treatment of active TB beyond initial screening. Serial screening strategies may lead to earlier TB treatment in patients receiving ongoing HIV care in resource-limited settings.

Jails are a unique setting for health education. The Tuberculosis (TB) Prevention Project was designed to improve completion of care for latent TB infection in released inmates. As part of an ongoing clinical trial to improve rates of completion, educators provided TB-focused educational sessions to 1,027 inmates. This article describes the educational sessions and illustrates some of the barriers to working in a jail setting and strategies to overcome them. The nature of the jail itself, inmate characteristics, the characteristics of educators, and the educational sessions themselves interacted in different ways to enhance or impair the interaction. Jail is a setting in which the population is at high risk for a number of health problems and health education is increasingly important.

The Brazilian public health system has implemented free, universal access to antiretroviral (ARV) therapy for HIV-infected patients. To evaluate this system, we performed a pilot study to determine whether ARVs were prescribed according to Brazilian guidelines in place in 2000, and whether prescriptions were refilled in a timely manner. Year 2000 data were abstracted from all medical and pharmacy records of adult patients first registered for HIV/AIDS care in a Rio de Janeiro public clinic from January to June 2000 (n = 67). Results were analysed using frequency analyses, chi-square tests and logistic regression. The patient sample was 41.8% female and had a mean age of 34.9 years. 54 (81%) had AIDS; total sample mean baseline CD4+/viral counts were 276 cells/mm3 and 237 517 copies per millilitre, respectively. Delays between clinic request and receipt of first CD4+/viral load results ranged from 25 to 107 (mean 66) and 33 to 139 (mean 86) days, respectively. Fifty-nine patients (88.1%) were prescribed ARV treatment. Forty-two regimens (71.2%) were highly active antiretroviral therapies; 17 (28.8%) were combination regimens with two nucleoside reverse transcriptase inhibitors. No combinations were prescribed that were contraindicated in Brazilian guidelines, however 33 patients (55.9%) were prescribed ARV drugs before one or both HIV status parameters (initial CD4+ level or viral load) were recorded. Fourteen patients prescribed ARVs (23.7%) lacked a supply of medication for >1 month during the year at least once. Of these patients, 11 had treatment lapses as a result of failure to pick up medications, and three lacked medication because of drug shortages. Medication lapses were associated with female sex, being hospitalized in 2000, and having more than two drugs in regimen, but were not associated with age, CD4+ level or use of ARVs before 2000. The results from this pilot study suggest conservative prescription of HAART, high practitioner adherence to guidelines, and some problems with refilling medications in a timely manner. Monitoring delays were identified as a structural limitation to optimal adherence to practice guidelines. Better access to monitoring-laboratory facilities and greater drug availability would improve programme success.