Background. Despite the benefits of antiretroviral therapy (ART), tuberculosis (TB) is the leading cause of mortality among human immunodeficiency virus (HIV)-infected persons in Africa. Nigeria bears the highest TB burden in Africa and second highest HIV burden globally. This long-term multicenter study aimed to determine the incidence rate and predictors of TB in adults in the Harvard/AIDS Prevention Initiative in Nigeria (APIN) and President's Emergency Plan for AIDS Relief (PEPFAR) Nigeria ART program.Methods. This retrospective evaluation used data collected from 2004 to 2012 through the Harvard/APIN PEPFAR program. Risk factors for incident TB were determined using multivariate Cox proportional hazards regression with time-dependent covariates.Results. Of 50 320 adults enrolled from 2005 to 2010, 11 092 (22%) had laboratory-confirmed active TB disease at ART initiation, and 2021 (4%) developed active TB after commencing ART. During 78 228 total person-years (PY) of follow-up, the TB incidence rate was 25.8 cases per 1000 PY (95% confidence interval [CI], 24.7–27.0) overall, and it decreased significantly both with duration on ART and calendar year. Risk factors at ART initiation for incident TB included the following: earlier ART enrollment year, tenofovir-containing initial ART regimen, and World Health Organization clinical stage above 1. Time-updated risk factors included the following: low body mass index, low CD4+ cell count, unsuppressed viral load, anemia, and ART adherence below 80%.Conclusions. The rate of incident TB decreased with longer duration on ART and over the program years. The strongest TB risk factors were time-updated clinical markers, reinforcing the importance of consistent clinical and laboratory monitoring of ART patients in prompt diagnosis and treatment of TB and other coinfections.

Total RIF resistance indicative of MDR-TB in treatment-naive patients was 5.52%, far exceeding the World Health Organization predictions (0 to 4.3%). RIF resistance was found in 6/213 (2.8%) cases, INH resistance was found in 3/215 (1.4%) cases, and MDR-TB was found in 8/223 (3.6%) cases. We found significantly different amounts of DR-TB by location (18.18% in the south of the country versus 3.91% in the north central region [P < 0.01]). Furthermore, RIF resistance was genetically distinct, suggesting possible location-specific strains are responsible for the transmission of drug resistance (P < 0.04). Finally, GenoType MTBDRplus correctly identified the drug-resistant samples compared to sequencing in 96.8% of cases. We found that total DR-TB in HIV-infection is high and that transmission of drug-resistant TB in HIV-infected patients in Nigeria is higher than predicted. Human immunodeficiency virus (HIV) greatly increases the risk for tuberculosis (TB), and the two epidemics continue to fuel one another (31). HIV-infected patients are significantly more likely to develop active TB diseases than non-HIV-infected people and are more likely to die from TB (13,27,28). In subSaharan Africa, 30% of HIV-infected patients who are diagnosed with TB die 12 months after the initiation of treatment (12,33). With an estimated national prevalence of HIV in Nigeria of 3.6% (7), the number of people living with HIV (3.3 million) represents the second largest burden of disease on the continent (32). Nigeria has the world's third largest TB burden, with the prevalence of 830,000 cases. The World Health Organization (WHO) estimates that 26% of patients with TB infection in Nigeria are HIV infected (37).Multidrug-resistant TB (MDR-TB), defined by resistance to isoniazid (INH) and rifampin (RIF), is a growing global health problem (5,19,22). While MDR-TB emerges as a consequence of poor adherence to anti-TB treatment (34,35), it can also be transmitted. MDR-TB results in significantly higher mortality rates in HIV-infected patients than drug-susceptible TB (18). The estimates based on modeling predict MDR-TB prevalence in Nigeria to range from 1.8% (0.0 to 4.3%) for new cases up to 7.7% (0.0 to 18.0%) for previously treated patients (36). Currently in Nigeria, streptomycin is the only treatment available for patients previously treated for TB or suspected of infection with MDR-TB. Furthermore, MDR-TB in HIV-infected individuals leads to higher mortality compared to mortality in non-HIV-infected patients or HIV-infected individuals with susceptible TB (18,24). These findings, combined with alarming evidence that MDR-TB can be transmitted, calls for close monitoring of the incidence of drug resistance, especially in HIV-infected populations (6).The conventional methods of drug resistance testing involve growth of Mycobacterium tuberculosis on liquid or solid culture medium (35). Culture methods are costly and time-consuming, thus limiting both utility for patient care and likelihood of timely treatment. Recently, several new commerci...

BackgroundXpert MTB/Rif (Xpert) is described as a game changer in tuberculosis (TB) control. We evaluated the impact of Xpert on diagnosis, time to treatment, and treatment outcome among patients with HIV associated TB in Nigeria.MethodsAdults with HIV being evaluated for pulmonary TB (PTB) were consecutively enrolled into the study cohort. At baseline, expectorated sputa were examined using Xpert and smear microscopy for Mycobacterium tuberculosis (MTB) and acid fast bacilli, respectively. Patients diagnosed with TB were followed-up until 6 months post TB diagnosis. TB was defined as sputum positive by smear microscopy, Xpert detection of MTB (bacteriologically confirmed case), or clinician diagnosed TB with initiation of full TB treatment (clinical diagnosis). Time to treatment was time from first clinic presentation for TB evaluation to initiation of TB treatment. We examined the proportion PTB patients with a positive Xpert result and compared time to TB treatment and outcome of TB treatment in patients based on sputum test results.ResultsA total of 310 adults with HIV were enrolled. The median CD4 cell count was 242 (interquartile range (IQR) 120–425) cells/mm3 and 88.1% were receiving antiretroviral therapy (ART). PTB was diagnosed in 76 (24.5%) patients, with 71 (93.4%) being bacteriologically confirmed. Among patients with PTB, 56 (73.7%) were Xpert positive. Median time to treatment was 5 (IQR 2–8) days and 12 (IQR 5–35) days in patient with and without Xpert positive results, respectively; p = 0.005. Overall 73.1% had symptom free survival at 6 months post PTB treatment initiation with no significant differences observed based on TB test method. 10 (14.9%) died within 6 months of TB treatment initiation. In analysis adjusted for age, sex, and mode of diagnosis (Xpert positive or negative), only ART use independently predicted mortality (AOR 0.10; 95% CI 0.01–0.93).ConclusionThe use of Xpert for routine care reduced time to PTB treatment, but did not improve survival in patients with HIV treated for susceptible PTB.

Background: Nurses are particularly vulnerable to nosocomial tuberculosis (TB) infection because, being in the frontline of healthcare provision, they are frequently exposed to patients with infectious TB disease. Although costeffective measures are available for TB infection control (TBIC), they are often poorly implemented. Knowledge of TBIC is known to positively influence the practice of the measures. There is, however, paucity of data on the knowledge and practices regarding TBIC among nurses in Nigeria. This study was aimed at determining the levels of TBIC-related knowledge and practices of nurses in Ibadan, and their associated socio-demographic factors.Methods: This cross-sectional study utilized a self-administered questionnaire to collect data from 200 nurses in two secondary health facilities, in May 2014. The mean knowledge and practice scores of the nurses were determined and logistic regression was utilized to explore the association between the scores and sociodemographic characteristics. Results: The respondents had mean knowledge and practice scores of 68.2 and 79.9% respectively. Using cut-off points of 80 and 100% for good knowledge and practice scores respectively, small proportions of the nurses had good scoresknowledge (10.5%) and practice (6%). Knowledge was not significantly associated with the sociodemographic characteristics of the nurses. Work experience was the only factor that was significantly associated with practices, with the more experienced nurses (> 18 years of work experience) having lower odds of obtaining good practice scores (OR 0.25, 95% CI 0.06-0.94). There was also no significant association between knowledge and practice scores (the nurses were yet to be trained on the newly-introduced TBIC package at the time of the study). Conclusions:The study revealed that small proportions of the nurses had good knowledge and practice scores. Its findings will be useful for the designing of interventions to improve TBIC among nurses and other healthcare workers, and to benchmark evaluation of the interventions. It is recommended that nurses should be trained on TBIC to equip them with necessary knowledge and skills. This, together with appropriate policy directives, and adequate monitoring and supervision will contribute to optimal implementation of TB preventive measures.