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Projects in urban counties, among Haitians
In Florida, partnerships between TB and HIV health care providers are starting to pay off with a decrease in TB cases, says David Ashkin, MD, medical advisor to the state’s TB control program. "Instead of the old way of doing business, where we had separate programs, we decided we wanted to start putting TB into programs that dealt with vulnerable populations," says Ashkin.
Two years ago, TB cases in the state appeared to have leveled off, adds Ashkin. Now, however, TB controllers think they’ll see a drop in cases of about 10%, once last year’s case count is completed.
HIV providers routinely screen for TB
Two programs under way are helping make the difference, Ashkin says. First, TB controllers have mounted a long-term effort to get short-course prophylaxis into HIV-infected populations in Broward and Dade Counties. "Two and half years ago, we went to HIV-care providers in those two counties," Ashkin says. "We integrated routine TB screening into the clinics, using TB program personnel and expertise."
Co-infected patients have tolerated the short-course prophylaxis (consisting of rifabutin and pyrazinamide) remarkably well, he adds. "Compliance rates have been about 90%," he says. "Tolerance has been very good. We’re reading about side effects from this regimen, but that’s not what we’re seeing here," he adds.
One reason for that may be that HIV-infected patients are used to coping with side effects, Ashkin says. "Unfortunately, these individuals are taking so many medications with side effects that side effects become a way of life," he says. By comparison, motivation isn’t nearly as high for someone "who’s a healthy individual, who’s not experiencing any symptoms, and who has a small chance of actually developing active disease," he adds.
Another plus for the short-course regimen is that it’s finite, he points out. "A lot of [HIV-infected people] have the mindset that they’re going to be taking medications for the rest of their lives," he says. "Here’s a situation where you take medication for two months — and that’s it!" Once the threat of developing TB is explained to them, HIV-infected patients tend to appreciate the risk of disease as well as the benefit prophylaxis can bestow, he adds.
Like sparks in a gas-filled room
Screening for TB at HIV clinics has turned up more than just candidates for prophylaxis. "We’ve actually turned up several active cases," he says. "That’s very scary. If they’d gone undetected, they’d be sitting in these clinics surrounded by other people with HIV, spreading disease to this extremely vulnerable population."
Instead, TB cases in Broward and Dade have been dropping — although Ashkin adds that part of what’s happening could also be attributable to the wider availability of triple-therapy regimens for AIDS, he adds.
The state’s Haitian community, another population with high rates of co-infection with HIV and TB, is the target of another effort to integrate HIV and TB programs, Ashkin says. "Haitians only make up 4% of our population in the state, but they account for 26% of our foreign-born TB cases," he points out. As in Dade and Broward, TB controllers have begun to partner with agencies serving the HIV-infected portion of the Haitian population; but in this case, getting a handle on the scope of the problem is proving trickier.
"You can’t say all Haitians are infected with HIV," he says. "What’s clear is that among those with TB, the real problem is HIV." What complicates surveillance work for both HIV and TB infection is that the Haitian community is very close-knit, with its own deeply held traditions. The result, Ashkin adds, is that many Haitians are resistant to incursions by outsiders and suspicious of Western-style medicine.
Studies from an immigrant processing center in Guantanamo Bay, Cuba, suggest that TB infection rates may be as high as 50%. An added complication is that many Haitians travel back and forth to their homeland, where they may be exposed to TB again and again.
To see whether there is ongoing transmission of TB among Haitians, TB controllers are doing DNA fingerprinting, says Ashkin. To try to figure out whether Haitians are bringing TB back from visits home, TB controllers are collaborating with researchers in Haiti to get isolates for comparison.
If studies point to recurring reinfection, then prophylaxis for this population may not be short-course at all, but may have to be prolonged, Ashkin notes.
"This is an instance where it’s so important that we in TB don’t work in isolation from other parts of public health," Ashkin says. "In this case, TB travels on the coattails of HIV. I compare it to sparks in a roomful of gas: Sooner or later, something is going to ignite."