Doris Duke Charitable Foundation

2007 ORACTA Grantee

Community-Based Case Finding of TB-HIV Patients

Principal Investigator:

• Christopher C. Whalen, M.D., M.S., Case Western Reserve University

Co-Investigators:

• Juliet Sekandi, M.B.Ch.B., M.S., Makerere University, Uganda
• Alphonse Okwera, M.B.Ch.B., M.Sc., Mulago Hospital Complex, Uganda
• Henry Luzze, M.B.Ch.B., M.S., Mulago Hospital Complex, Uganda

Abstract

Tuberculosis is an ancient disease that continues to plague humans. Although tuberculosis is contained in many industrialized countries, it remains a threat to both individual and public health in developing countries, especially in sub-Saharan Africa. In Africa, tuberculosis has re-emerged as a threat because of the contemporary epidemic of the human immunodeficiency virus type-1 (HIV). Indeed, HIV and tuberculosis are tightly linked and are often referred to as sister epidemics.

Before 2003, the management of HIV-infected patients with tuberculosis was simply to treat the tuberculosis because effective ways to treat HIV were not yet widely available in Africa. After 2003, with the financial commitments from the Presidential Emergency Plan for AIDS Relief (PEPfAR) and the Global Fund of the World Bank, there has been a rapid expansion of services to provide life-saving antiretroviral medicines to treat HIV. Health care professionals in Africa now have the means to treat their HIV-infected patients with tuberculosis.

The ability to treat HIV and tuberculosis together requires a proper diagnosis of both diseases. Early diagnosis of patients with both HIV and tuberculosis is imperative for it can reduce mortality and prevent further spread of these diseases to other people. Currently, most tuberculosis control programs around the world rely on passive case finding to detect new cases of tuberculosis. In passive case finding, tuberculosis patients are identified at clinics or hospitals after the patient has decided to seek care. Our preliminary research in Kampala, Uganda, has shown that passive case finding is associated with unnecessary delays in the diagnosis and treatment of HIV and tuberculosis.

The premise of our proposal is that active case finding will improve case detection of tuberculosis, identify cases at an earlier point in their disease, and will enhance detection of HIV-infected cases because of the tight link between HIV and tuberculosis. But active case finding can take many forms. Since the optimal form for accessing HIV-associated tuberculosis is unknown, we will evaluate two innovative community-based approaches to enhance early entry into an integrated care program for HIV and tuberculosis. In one approach, we will look for tuberculosis and HIV infection in the household contacts of infectious tuberculosis cases; in the other approach, we will look for tuberculosis and HIV infection in people with a cough lasting more than two weeks, identified in a door-to-door survey. With this information, we will be able to compare the effectiveness of each method to identify early tuberculosis cases and to compare the cost(s) of detecting one case of HIV and tuberculosis in the community. The findings of this study will inform policy about the effectiveness of active case finding in national tuberculosis programs where HIV is common.

These aims will be achieved through a longstanding collaboration between Case Western Reserve University and Makerere University. The program will be built upon capacity already supported by federally funded research on tuberculosis and HIV and by the PEPfAR program entitled ‘Provision of Routine HIV Testing, Counseling, Basic Care and Antiretroviral Therapy at Teaching Hospitals in the Republic of Uganda.’