Multidrug-resistant tuberculosis (MDR-TB) is a possible threat to global tuberculosis control. Despite a disease prevalence of 263/100 000 population Pakistan lacks information on prevalence of drug resistant TB. Our objective was to estimate prevalence of MDR and associated risk factors in patients with pulmonary tuberculosis in Karachi. Six hundred and forty consenting adult patients were enrolled from field clinics from July 2006 to August 2008 through passive case finding. Prevalence of MDR-TB with 95% confidence interval (CI) was calculated with Epi-Info. Logistic Regression analyses were performed for risk factors associated with MDR. Overall MDR rate was 5.0%, 95% CI: 3.3-6.6% (untreated 2.3%, treated 17.9%). Mean age was 32.5 (+/-15.6) years and there were 292 (45.6%) females and 348 (54.4%) males. Factors independently associated with MDR were: female gender (OR 3.12; 95% CI: 1.40-6.91), and prior history of incomplete treatment (OR 10.1; 95% CI: 4.71-21.64). Ethnic groups at higher risk for MDR included Sindhis (OR 4.5; 95% CI: 1.42-14.71) and Pashtoons (OR 3.6, 95% CI: 1.12-11.62). This study reports an overall MDR rate of 5.0% in our study population. It further highlights the need for MDR prevention through re-focusing Directly Observed Treatment, Short-course DOTS delivery with emphasis on women and certain high risk sub groups.

An MDR-TB rate of 2.4% is reported in new patients. Low RIF monoresistance supports the use of RIF as a marker for MDR-TB in this population. The need to strengthen TB care in the identified at-risk groups is emphasized. Based on INH resistance rates, a review of national treatment/prevention regimens relying on INH is suggested.

ObjectiveTo describe feasibility and results of systematic screening of tuberculosis (TB) patients for HIV.DesignCross-sectional study.SettingSix selected sentinel sites (public DOTS clinics) in the province of Sindh, Pakistan.ParticipantsAll TB patients aged 16–60 years registered for treatment from April 2008 to March 2012.MeasurementDemographic information of registered TB patients, screening for HIV through rapid testing and confirmation by referral lab of Sindh AIDS Control Program, according to national guidelines.ResultsOf a total of 18 461 registered TB patients, 12 882 fulfilled the inclusion criteria and were given education and counselling. Of those counselled 12 552 (97.4%) were screened for HIV using a rapid test. Men made up 48% of the sample and 76.5% of patients had pulmonary TB. Of the total patients tested, 42 (0.34%) were HIV-positive after confirmatory testing at the Sindh AIDS Control Program Laboratory. Prevalence of HIV among male patients was 0.67% whereas prevalence among female patients was 0.03% (p value <0.001). Prevalence of HIV among pulmonary TB patients was 0.29% and among extrapulmonary TB patients was 0.48% (p value=0.09).ConclusionIn public DOTS clinics in Pakistan it is feasible to test TB patients for HIV. Prevalence of HIV is three times higher among TB patients as compared with the general population in Pakistan. Although the results are not representative of Pakistan or Sindh province they cover a large catchment area and closely match WHO estimate for the country. Routinely screening all TB patients for HIV infection, especially targeting men and ensuring antiretroviral therapy, can significantly improve TB/HIV collaborative activities in Pakistan and identify many cases of HIV, improve health outcomes and save lives.

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Pakistan has the highest multidrug-resistant (MDR) tuberculosis (TB) burden in the Eastern Mediterranean region of the World Health Organization (WHO) (12). Fluoroquinolones (FQ) are an integral component of second-line therapy for multidrug-resistant strains (11). FQ resistance among Mycobacterium tuberculosis strains is reported in regions with high quinolone usage (1). Such regions also include Pakistan, with over-thecounter antimicrobial prescriptions and extensive FQ usage (2). National TB surveillance data to assess prevalence of FQ resistance in the country are not available. The current study was conducted to determine FQ resistance in M. tuberculosis at a community level.Methods. This study was conducted in Karachi, the largest city in Pakistan. Our study sites included 10 field clinics run by the Marie Adelaide Leprosy Centre (MALC), a nongovernmental organization working in partnership with the government of Pakistan. These clinics, within Karachi, are located in low-socioeconomic, highly populated administrative units. Patients are either self-referred or referred by their nearby general practitioners. The prevalence of FQ resistance was estimated through a study of consenting adult patients with a clinical suspicion of pulmonary TB at initial enrollment.Early-morning sputum specimens were collected and transported to the clinical laboratory of the Aga Khan University Hospital (AKUH) for smear examination, culture, and drug susceptibility testing (DST). AKUH laboratory is accredited by the Joint Commission of International Accreditation (JCIA) and by World Health Organization (WHO) Supranational Laboratory external quality assurance for first-and second-line drug susceptibility testing.Both LJ and MGIT (Becton Dickinson) were used for the isolation of M. tuberculosis for all specimens. M. tuberculosis was identified by the Bactec NAP TB differentiation test (Becton Dickinson), growth in p-nitrophenyl butyrate (PNB)-containing medium, nitrate reduction, and niacin accumulation (10). Susceptibility testing was performed using the agar proportion method on enriched Middlebrook 7H10 medium (BBL) at the following concentrations: rifampin (R), 1 g/ml; isoniazid (H), 0.2 g/ml and 1 g/ml; and ethambutol (E), 5 g/ml. Pyrazinamide (Z) sensitivity was carried out using the Bactec 7H12 medium (pH 6.0) at 100 g/ml (Bactec PZA test medium, Becton Dickinson) (9). FQ susceptibilities were determined with ciprofloxacin (2 g/ml) from 2006 to 2008 and with ofloxacin (2 g/ml) from 2009 onward (9). M. tuberculosis H37Rv was used as a control with each batch of susceptibility testing. MDR was defined as resistance to both isoniazid (0.2 g/ml) and rifampin.Spoligotyping was performed on all FQ-resistant strains using a commercially available kit provided by Isogen Life Science B.V., Maarssen, Netherlands. DNA was extracted by the cetyltrimethylammonium bromide (CTAB) method (6). Spoligotyping based on the 43 spacers of the direct repeat (DR) region of the M. tuberculosis complex was carried out using primers DRa (5Ј GGTTTT...