The study demonstrates the feasibility and acceptance of screening large number of TB patients for HIV and linking them to antiretroviral treatment. Our study found a threefold-higher prevalence of HIV among TB patients compared with the general population, and the overwhelming majority of the HIV-infected TB patients detected were men.
The prevalence of HIV among TB patients was found to be 0.34% and while this figure is considerably less than 12%, WHO's estimate of HIV among the world TB patients is in line with the estimates for Pakistan (0.3%).3
In Pakistan the male-to-female ratio in the reported HIV cases is 10
This gender difference was also evident in HIV positive TB patients in our study. The prevalence of HIV was 22 times higher among male TB patients (0.67%) compared with female TB patients (0.03%). Sexual promiscuity has been reported as less common among female population as compared with male population in Pakistan.7
Moreover a significant number of reported HIV/AIDS cases in Pakistan have been male overseas Pakistani workers, deported from Gulf countries.9
Because of extramarital sexual activities of these male workers they are at greater risk of HIV infection.10
Furthermore the current HIV epidemic in Pakistan is partially driven by injection drug users (IDUs), and the vast majority of IDUs in Pakistan are men.11
Prevalence of HIV among IDUs in Karachi in Pakistan is up to 42.2%.12
Prevalence of HIV infection was 1.65 times higher among extrapulmonary TB cases as compared with pulmonary TB cases in our study (prevalence 0.48% vs 0.29% p value 0.09). Although the difference is insignificant this could be due to small number of HIV cases detected in our study. This result compares favourably with a similar study done in India in which it was found that HIV infection is 1.3 times more likely among the extrapulmonary patients.4
Similar results have been observed in studies done in developed countries.13
Refusal rate for HIV testing in our study was <3%. Since TB patients received education about HIV/AIDS by trained community mobilisers and were counselled for HIV testing, this resulted in low refusal rate in our study. In similar study done in India a refusal rate of 7.8% was observed.4
Screening of 12 552 TB patients in six sentinel sites with low-refusal rate suggests that screening of TB patients in DOTS treatment centres is feasible and the concerns about high refusal rate are not legitimate.
This study has a couple of important limitations. The study area was confined to six public facilities in Sindh. While all TB patients between 16 and 60 were approached for inclusion in the study the results cannot be assumed to be representative of Pakistan or even Sindh province. However, our results cover a fairly large catchment area and closely mirror the WHO estimates for the country. We were also not able to test TB patients that receive care in the private sector.14
We were unable to get confirmed data on the smear status of the TB patients. This limits the ability to better disaggregate the data analysis and should be considered in future associations.
In Pakistan the number of patients diagnosed each year with TB is about 400 000. If all of these cases were screened for HIV, about 1200 more cases of HIV could be detected each year. In Sindh, there are around 70 000 TB cases reported each year and the potential for HIV case detection scalable screening are still quite large. As a result of this study 35 patients were put on ART. Our results demonstrate the feasibility of implementing WHO TB/HIV guidelines in Pakistan. By scaling up the screening and linking detected HIV cases to ART centres, the spread of HIV may be better controlled in Pakistan and outcome of TB treatment can be improved and many lives can be saved.15