A multicountry cohort study in sub-Saharan Africa by Landon Myer and colleagues reveals higher pregnancy rates in HIV-infected women on antiretroviral therapy (ART).

Sputum smears for acid-fast bacilli (AFB) are the primary methods for diagnosis of tuberculosis (TB) in many countries. The tuberculin skin test (TST) is the primary method for diagnosis of latent TB infection (LTBI) worldwide. The poor sensitivity of the former and the poor specificity of the latter warrant the development of new tests and strategies to enhance diagnostic capabilities. We evaluated the sensitivity of an "in-tube" gamma interferon release assay (IGRA) using TB-specific antigens in comparison to the TST and the sputum smear for AFB in TB cases in South Africa. The sensitivity of the IGRA for TB was considered a surrogate of sensitivity in LTBI. Among 154 patients with a positive culture for Mycobacterium tuberculosis, the sensitivity of the IGRA for the diagnosis of TB varied by clinical subgroup from 64% to 82%, that of the TST varied from 85% to 94%, and that of two sputum smears for AFB varied from 35% to 53%. The sensitivity of the IGRA in human immunodeficiency virus (HIV)-infected TB cases was 81%. HIV-infected TB patients were significantly more likely to have indeterminate IGRA results and produced quantitatively less gamma interferon in response to TB-specific antigens than HIV-negative TB patients. The overall sensitivity of the TST in all TB cases was higher than that of the IGRA (90% versus 76%, respectively). The combined sensitivities of the TST plus IGRA and TST plus a single sputum smear were 96% and 93%, respectively. The TST combined with IGRA or with a single sputum smear may have a role in excluding the diagnosis of TB in some settings.Worldwide, there were 8.8 million new cases of active tuberculosis (TB) and an estimated 1.7 million deaths from TB in 2003 (32). With increased numbers of TB cases, health systems in resource-limited settings face difficulties in coping with the large patient and specimen loads (16). Sputum smear for acidfast bacilli (AFB) (two or three smears) is the primary microbiologic method used for diagnosis of TB in resource-limited settings. Cultures for AFB require more extensive laboratory facilities, and their cost can be prohibitive. However, there is concern regarding this dependence on the sputum smear for AFB due to its limited sensitivity. Human immunodeficiency virus (HIV) coinfection can further complicate TB diagnosis with an atypical clinical picture of pulmonary TB and a higher likelihood of negative sputum smears for AFB (7,8,12,13,25). The tuberculin skin test (TST) is the standard for diagnosis of latent tuberculosis infection (LTBI), is the only test available for that purpose in resource-limited settings, and is sometimes used to aid in the diagnosis of active TB; however, its specificity is limited by cross-reactivity with nontuberculous mycobacteria and BCG vaccine strains of Mycobacterium bovis, and its sensitivity can be affected by malnutrition and immunosuppression (17,27).Because of the efficacy of current therapeutic options, the need is great for affordable and rapid diagnostic methods with high sensitivity and specificity fo...

Summaryobjectives To describe a family-focused approach to HIV care and treatment and report on the first 2 years experience of implementing the mother-to-child transmission (MTCT)-plus program in Abidjan, Cô te d'Ivoire.program The MTCT-plus initiative aims to enrol HIV-infected pregnant and postpartum women in comprehensive HIV care and treatment for themselves and their families. Of their 568 male partners reported alive, 52% were aware of their wife's HIV status and 30% were tested for HIV; 53% of these tested partners were found to be HIV-infected and 78% enrolled into the program. Overall only 10% of the women enrolled together with their infected partner. On the other hand, the program involved half of the seronegative men who came for voluntary counselling and testing (VCT) in the care of their families. Of 1624 children <15 years reported alive by their mothers (excluding the last newborn infants of the most recent pregnancy systematically screened for HIV), only 10.8% were brought in for HIV testing, of whom 12.3% were found to be HIV-infected.lessons learned and challenges The family-focused model of HIV care pays attention to the needs of families and household members. The program was successful in enrolling HIV women, their partners and infants in continuous follow-up. However engaging partners and family members of newly enrolled women into care involves numerous challenges such as disclosure of HIV status by women to their partners and family members. Further efforts are required to understand barriers for families accessing HIV services as strategies to improve partner involvement and provide access to care for other children in the households are needed in this West African urban setting.

ObjectivesThe aim of the study was to determine the incidence of, and risk factors for, nevirapine (NVP)-associated hepatotoxicity and rash in HIV-infected Thai men and women, including pregnant women, receiving NVP-containing highly active antiretroviral therapy (HAART). MethodsNVP-containing HAART was prescribed to eligible men and women enrolled in the Prevention of Mother-To-Child Transmission of HIV (PMTCT) and MTCT-Plus programmes. All pregnant women received zidovudine (ZDV)/lamivudine (3TC)/NVP from 414 weeks of gestational age if their CD4 cell count was 200 cells/mL or from 428 weeks if their CD4 cell count was 4200 cells/mL. Patients followed for at least 8 weeks after starting HAART or until delivery were included in the analyses. ResultsOf 409 patients, 244 were pregnant women, 87 were nonpregnant women and 78 were men. Hepatotoxicity occurred in 15.6% of all patients. Men had a significantly higher rate of asymptomatic hepatotoxicity (P 5 0.021). Pregnant women receiving HAART for PMTCT (92% had CD4 cell counts 4250 cells/mL) had a significantly higher rate of symptomatic hepatotoxicity (P 5 0.0003) than pregnant women receiving HAART for therapy. Rash occurred in 16.1% of all patients. The patients' sex and baseline CD4 cell count were not associated with the risk of hepatotoxicity or rash. NVP was discontinued in 4.2% and 6.8% of patients because of hepatotoxicity and rash, respectively. ConclusionsThe incidence of NVP-related hepatotoxicity and rash in Thai adults is similar to incidences reported for other populations. While larger studies are needed, our data support continued use of NVP-containing regimens as first-line treatment in developing countries for HIV-infected patients, including pregnant women. Pregnant women with high CD4 cell counts may experience higher rates of symptomatic hepatotoxicity and thus require careful clinical and laboratory monitoring.