TB skin-testing rate low for new HIV infections
TB prevention needs improvement
Research shows that it would be good public policy to target TB prevention policies, programs, and prophylaxis to people infected with HIV since this population is 100 times more likely to develop active tuberculosis compared with uninfected people if latent TB infection is present. Yet, tuberculin skin testing is not routinely performed on as many as half of those newly diagnosed with HIV, according to a study presented at the 14th International AIDS Conference held in Barcelona, Spain in July.
"Half of persons newly diagnosed with HIV had a tuberculin skin test (TST) following HIV diagnosis documented in their medical records," says Lisa M. Lee, PhD, senior epidemiologist for the Centers for Disease Control and Prevention (CDC) in Atlanta. "There was little variation by demographic group," she says. "This signals a need to improve TB prevention among persons with HIV beginning with better coverage of TST screening."
Recommendations not being followed
The study’s findings also indicate that not enough clinicians are adhering to recommendations by the Infectious Diseases Society of America and the U.S. Public Health Service, both of which support testing all persons who have been newly-diagnosed with HIV infection, Lee reports.
The study’s objective was to assess missed opportunities for prevention of TB through the selection of a population-based random sample of 1,093 persons diagnosed and reported with HIV from June 1995 through June 1997 in Seattle/King County, WA; New Orleans, and Jersey City, NJ.1
Medical reviews at reporting providers were conducted to determine the proportion of patients receiving a TST following HIV diagnosis, and investigators found that of 869 people, for whom there were completed reviews, 52% had a TST following HIV diagnosis.1 Excluded were 21 active TB cases and seven previous TST positives, and of the 437 people with TST, 33 (7.5%) were positive.1
There was a one-month median time between HIV diagnosis and TST, and the mean was 5.7 months, with 83.3% having the TST within one year of HIV diagnosis.1 The study also found that there was no difference in the proportion of TST by sex or race.1
HIV-infected persons who are not tested for TB and who have latent TB infection won’t receive the prophylaxis necessary to prevent the development of active tuberculosis. "All persons with HIV who have a positive TST result but do not have evidence of active disease or a history of treatment should be treated for latent TB infection," Lee says. "There are also special situations when HIV-infected persons should be treated for latent TB infection regardless of TST results," Lee adds. "Because of recent reports of fatal and severe liver injury associated with treatment of latent TB infection among HIV-positive persons, certain regimens are not recommended."
Clinicians seeking treatment guidelines published by the U.S. Public Health Service and the IDSA are available on the CDC’s web site at www.cdc.gov. Ideally, clinicians will educate HIV-infected patients and those at risk for HIV about TB prevention, along with any HIV education that is provided. "HIV-infected persons should be advised that certain activities and occupations can increase the risk for exposure to TB," Lee says.
"In addition, clinicians can help prevent active TB among persons with HIV by evaluating all persons with newly diagnosed HIV-infection for TB infection," she adds. "With appropriate treatment for latent TB infection, active TB disease can be prevented."
Likewise, when patients are diagnosed with TB, clinicians should recommend voluntary HIV counseling and testing because TB and HIV are associated and early diagnosis of both infections is advantageous, Lee notes. When HIV-infected patients have a positive TST it’s important to help them prevent active TB disease and monitor to ensure compliance with treatment for latent TB infection, she says.
Reference
1. Lee LM, Buskin SE, Morse A, et al. Low rates of tuberculin skin testing among persons with newly diagnosed HIV infection, U.S., 1995-1997. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 7-12, 2002: Abstract ThPeC7560.
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