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TB Challenge: Partnering to Eliminate TB in African Americans
Reported Tuberculosis and HIV-infection, 2005
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Suzanne Marks, MPH, MA and Elvin Magee, MPH, MS
In this article, we discuss the need for improvements in HIV
testing and reporting and potential populations who may most benefit
from these improvements. More persons might accept HIV testing if
rapid HIV diagnostics and opt-out testing were used. Prevention,
early diagnosis, and access to care for both diseases are especially
important for African-Americans, substance abusers, homeless
persons, and inmates due to the high burden of both HIV and TB in
these groups. Once HIV is diagnosed, TB can be prevented through
targeted efforts to diagnose and treat latent TB infection before TB
disease develops.
Globally, tuberculosis (TB) is the leading killer of people who
are HIV-infected. In the United States, patients with TB disease and
the human immunodeficiency virus (HIV) have over five times the odds
of dying during anti-TB treatment and over three times the odds of
being diagnosed with TB disease at death as HIV-uninfected patients.
This underscores the importance of prevention, early diagnosis, and
treatment for both TB and HIV. HIV is also the most important known
risk factor for progression to TB disease from latent TB infection (LTBI).
Two to eight percent of HIV-infected persons with LTBI progress to
TB disease each year within 5 years after infection, versus a total
of eight percent of HIV-uninfected persons with LTBI over a time
period of 60 years. Highly active antiretroviral therapy (HAART) has
been shown to reduce the risk of developing TB disease in
HIV-infected persons, and reduces TB relapse and death in patients
with TB disease. TB disease is an AIDS-defining opportunistic
condition. If individuals are diagnosed with TB disease, provider
knowledge of HIV infection and use of HIV medications is critical
for optimal patient management and for referrals to care to prevent
mortality and additional morbidities.
CDC has recommended HIV testing of all TB patients since 1989.
Routine HIV testing has been recommended since 2001, since targeted
testing based on provider assessment of patient risk behaviors fails
to identify a substantial number of HIV-infected persons. This is
because often the TB patients do not perceive themselves to be at
risk for HIV or do not disclose their risks. Routine HIV testing of
all TB patients can also reduce the stigma associated with testing.
CDC's revised HIV testing guidelines issued in September 2006 call
for “opt-out” HIV testing of all persons in clinic settings. Opt-out
testing means that the provider should perform HIV testing after
notifying the patient that: 1) the test will be performed, and 2)
the patient may elect to decline or defer testing.
Our study objective was to describe the recent
status of reported HIV infection in TB patients, HIV/TB comorbidity,
and the characteristics of HIV/TB patients in the United States. We
analyzed data reported for 2005 on HIV status from the National TB
Surveillance System. California data were excluded because the state
shares with CDC only the results of AIDS and TB registry matches.
HIV-positive or HIV-negative status is defined as “known.” HIV
prevalence equal to or greater than one percent of any specific
population is considered high.
In 2005, 69 percent of all TB patients had
known HIV status. Of the remaining 31 percent, nearly half were not
offered HIV testing and a quarter refused testing when offered. A
greater percentage of non-Hispanic black TB patients had known HIV
status (79 percent). For US-born non-Hispanic blacks, 77 percent had
known HIV status. Black females were more likely than black males to
have had unknown HIV status.
Text only version
- Data Tables
Text only version
- Data Tables
Black TB patients had the highest known
prevalence of HIV infection of the major race/ethnic groups: 17% vs.
8% of Hispanics, 5% of whites, 2% of American Indian/Alaska Natives,
and 1% of Asians. And, because of the high prevalence of both TB and
HIV among blacks, nearly two-thirds (63%) of patients having both TB
and HIV disease were black.
Text only version
- Data Tables
Text only version
- Data Tables
The graphs below show reported data on the
socio-demographics of TB patients by HIV status.
Text only version
- Data Tables
TB patients having exceptionally high (higher
than the average 9%) rates of HIV-infection included males, those
aged 25-44, those aged 45-64, non-Hispanic blacks, those of unknown
race/ethnicity, US-born persons, injection drug users (IDUs),
non-injection drug users, homeless persons, inmates, and alcohol
abusers. Substance abuse, homelessness, and incarceration are
factors associated with both HIV and TB incidence and transmission
of disease.
In summary, nearly one-third of all TB patients and one-fifth of
non-Hispanic black TB patients had unknown HIV status in 2005. HIV
prevalence was high in nearly all TB patient groups, with some
having exceptionally high HIV prevalence. Improvements in HIV
testing and reporting are needed. The use of “opt-out” HIV testing
and rapid HIV tests (with results available in < 20 minutes) may
facilitate improvements in knowledge of HIV status. TB can be
prevented through targeted efforts aimed at diagnosing and treating
latent TB infection before TB disease develops, especially in
substance abusers, homeless persons, and inmates. And, TB relapse
and mortality may be avoided by early access to HIV care and support
services. Because of the high burden of both HIV and TB in the
African-American community, prevention, early diagnosis, and access
to care are especially important for this population.
Last Reviewed: 05/18/2008 Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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