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1.  Perceptions of Tuberculosis Patients on Provider-Initiated HIV Testing and Counseling - A Study from South India 
PLoS ONE  2009;4(12):e8389.
The acceptability and feasibility of provider-initiated HIV testing and counseling (PITC) in many settings across Asia with concentrated HIV epidemics is not known. A pilot study of the PITC policy undertaken within the public health care systems in two districts in India offered the opportunity to understand patient's perspectives on the process of referral for HIV testing and linking to HIV treatment and care.
We conducted a cross-sectional study of randomly selected TB patients registered by the TB control program between July and November 2007 in two districts in south India. Trained interviewers met patients shortly after TB diagnosis and administered a structured questionnaire. Patients were assessed regarding their experience with HIV status assessment, referral for counseling and testing, and for HIV-infected patients the counseling itself and subsequent referral for HIV treatment and care.
Of the 568 interviewed TB patients, 455 (80%) reported being referred for HIV testing after they presented to the health facility for investigations or treatment for TB. Over half the respondents reported having to travel long distances and incurred financial difficulties in reaching the Integrated Counselling and Testing Centre (ICTC) and two-thirds had to make more than two visits. Only 48% reported having been counseled before the test. Of the 110 HIV-infected patients interviewed, (including 43 with previously-known positive HIV status and 67 detected by PITC), 89 (81%) reported being referred for anti-retroviral treatment (ART); 82 patients reached the ART centre but only 44 had been initiated on ART.
This study provides the first evidence from India that routine, provider-initiated voluntary HIV testing of TB patients is acceptable, feasible and can be achieved with very high efficiency under programmatic conditions. While PITC is useful in identifying new HIV-infected patients so that they can be successfully linked to ART, the convenience and proximity of testing centres, quality of HIV counseling, and efficiency of ART services need attention.
PMCID: PMC2791227  PMID: 20041167
2.  High risk behaviors of injection drug users registered with harm reduction programme in Karachi, Pakistan 
Surveillance data of Sindh AIDS Control Programme, Pakistan suggest that HIV infection is rapidly increasing among IDUs in Karachi and has reached 9% in 2004–5 indicating that the country has progressed from nascent to concentrated level of HIV epidemic. Findings of 2nd generation surveillance in 2004–5 also indicate 104/395 (26.3%) IDUs HIV positive in the city.
We conducted a cross sectional study among registered IDUs of a needle exchange and harm reduction programme in Karachi, Pakistan. A total of 161 IDUs were included in the study between October–November 2003. A detailed questionnaire was implemented and blood samples were collected for HIV, hepatitis B & C and syphilis. HIV, hepatitis B and C antibody tests were performed using Enzyme Linked Immunosorbent Assay (ELISA) method. Syphilis tests (RPR & TPHA) were performed on Randox kit.
Besides calculating frequencies univariate analysis was performed using t tests for continuous variables as age, age at first intercourse and average age of initiation of addiction and chi square for categorical variables like paid for sex or not to identify risk factors for hepatitis B and C and syphilis.
Average age of IDU was 35.9 years and average age of initiation of drugs was 15.9 years. Number of drug injections per day was 2.3. Shooting drugs in group sharing syringes was reported by 128 (79.5%) IDUs. Over half 94 (58.3%) reported paying for sex and 64% reported never using a condom. Commercial selling of blood was reported by 44 (28%). 1 of 161 was HIV positive (0.6%). The prevalence of hepatitis B was 12 (7.5%), hepatitis C 151 (94.3%) and syphilis 21 (13.1%). IDUs who were hepatitis C positive were more likely to start sexual activity at an earlier age and had never used condoms. Similarly IDUs who were hepatitis B positive were more likely to belong to a younger age group. Syphilis positive IDUs were more likely to have paid for sex and had never used a condom.
Prudent measures such as access to sterile syringes, rehabilitation and opiate substitution therapies are required to reduce high risk behaviors of IDUs in Pakistan.
PMCID: PMC1800841  PMID: 17291354
3.  HIV-infected workers deported from the Gulf States: impact on southern Pakistan 
International journal of STD & AIDS  1999;10(12):812-814.
HIV prevalence is still very low in Pakistan, but its south Asian location and subgroups with recognized lifestyle risk factors suggest that Pakistan will experience expanded diffusion of HIV. We report the frequency of HIV infections identified by the AIDS Control Programme on the Sindh province of Pakistan. Most HIV-positive cases currently reported to the Sindh AIDS Control Programme are found among Pakistani workers deported from the Gulf States and among foreigners. The 58 returned workers with HIV represent 61 to 86% of reported cases in any given year during the 1996–1998 period. Five wives of returning workers have been identified with HIV. Expatriate workers in the Gulf States are tested for HIV routinely, unlike other subgroups in Pakistan. Considering the risk of HIV/AIDS due to regular introduction of HIV from returned workers, and the limited awareness surrounding sexual health and HIV/STD transmission issues in Pakistan, intervention programmes targeted at overseas workers need to be implemented to control the expansion of the HIV epidemic in Pakistan.
PMCID: PMC2564791  PMID: 10639063
HIV; acquired immunodeficiency syndrome; migration; Pakistan; surveillance; Middle East
4.  Antiretroviral Drug Resistance Mutations Among Treated and Treatment-Naive Patients in Pakistan: Diversity of the HIV Type 1 pol Gene in Pakistan 
AIDS Research and Human Retroviruses  2011;27(12):1277-1282.
Pakistan is experiencing a growing HIV epidemic. Antiretroviral drugs (ARV) have been smuggled into the country and available without prescription since the early 1990s, but are now provided free of cost by the government. We assessed the prevalence of HIV-1, drug resistance, and subtype distributions. Blood specimens were collected from HIV-1-infected participants registered in Sindh Province on dry blood spot (DBS) cards in 2008. Pol, protease, and partial reverse transcriptase regions were sequenced after reverse transcriptase PCR (RT-PCR). HIV-1 subtype was assigned by phylogenetic analysis. Primary drug resistance was analyzed by the Calibrated Population Resistance (CPR) tool using the Stanford Surveillance Drug Resistance Mutation (SDRM) major mutation list. Out of 100 blood samples collected, 42 were suitable for testing. Out of 42, 11 were ARV-receiving and 31 ARV-naive patients. Among them, 24 were injection drug users (IDUs), four immigrants, two hijras (male transvestites), two men who have sex with men (MSM), four prisoners, one female sex workers, two spouses of HIV-infected persons, and four from the general population. ARV resistance among naive patients was 2/31 (6.5%) and 36.4% (4/11) among ARV-experienced patients making an overall resistance of 14.2%. HIV-1 subtype A1 was the predominant subtype found in 35/42 (83.3%) followed by CRF35_AD and C, 6.5% each. Subtype D and G were found in one (2.4%) each. A significant proportion of Pakistani HIV patients has ARV drug resistance. Physicians treating patients should consider the magnitude of drug resistance while selecting regimens, and address drug adherence aggressively.
PMCID: PMC3227241  PMID: 21591988
5.  Efficacy of Gatifloxacin in Acute Bacterial Corneal ulcer 
Pakistan Journal of Medical Sciences  2013;29(6):1375-1380.
Objective : To assess the efficacy of Gatifloxacin 0.3% ophthalmic solution in infective corneal ulcer.
Methods : This observational (non comparative) clinical analysis was done at the Department of ophthalmology unit-II, Liaquat University Eye hospital Hyderabad of Liaquat University of Medical and Health Sciences Jamshoro / Sindh, Pakistan from April 2010 to March 2012. All the subjects who fulfilled the inclusion criteria were registered. Anterior segment examination was performed. Corneal staining and sensitivity test was done to exclude viral and paralytic element. Corneal samples were collected for gram’s staining and culture sensitivity tests. After getting the preliminary laboratory results, Gatifloxacin 0.3% ophthalmic solution was used in bacterial corneal ulcer every 30 minutes for first twenty four hours, and every one hour till three days. On obtaining better response the drops were used every two hours up to 7 days. The treatment was continued with tapering of dosage for three weeks. After total recovery (re-epithelialization of corneal epithelium) the drops were used two times a day for one more week.
Results : The total of 170 patients (male=68.8%; female=31.2%) were recruited. Culture sensitivity examination revealed staphylococcus (36.5%), followed by fungi (24.1%). Pseudomonas thus detected were 10%. Gatifloxacin showed highest sensitivity and lowest resistance i.e. 87.65% and 12.35% respectively against gram positive and gram negative isolates.
Conclusion: Gatifloxacin 0.3% ophthalmic solution due to its strong activity against various gram-positive and gram-negative microbes is strongly effective in the treatment of acute bacterial keratitis.
PMCID: PMC3905397  PMID: 24550957
Bacterial Corneal ulcer; Gatifloxacin; gram-negative bacteria; Gram-positive bacteria; Therapeutic action
6.  Diagnostic value of an immunochromatographic test over clinical predictors for tuberculosis in HIV patients 
Clinical Epidemiology  2011;3:237-244.
The value of an immunochromatographic test for tuberculosis (ICT-TB) combined with clinical predictors has yet to be evaluated in Thailand. This study aimed to assess any additional diagnostic value of an ICT-TB test over that of clinical predictors in a group of human immunodeficiency virus (HIV) patients as well as in subgroups of HIV patients classified by clinical risk scores.
Patients and methods:
An extended cross-sectional study was conducted at a community hospital in Chiang Rai and a general hospital in Lampang. HIV patients registered between April 2009 and May 2010 were screened by a locally made ICT-TB test, including 38, 16, and 6 kD Microbacterium tuberculosis antigens, as well as by routine evaluations for TB diagnosis. Demographic data, medical history, signs, and symptoms were recorded. Participants were followed up for 2 months for final ascertainment of TB diagnosis.
Of 206 patients, 37 (18%) had TB. Four clinical predictors were identified: low body mass index (<19 kg/m2), prolonged cough (duration >2 weeks), shaking chills (≥1 week), and no use of antiretrovirals. The area under the receiver operating curve was 90.2%; adding the ICT-TB test result increased the area nonsignificantly to 91.6% (P = 0.40). When patients were categorized by risk scores derived from selected clinical predictors into low (scores ≤7) and high (scores >7) TB risk groups, a positive ICT-TB test increased the positive predictive value nonsignificantly in the low risk group (from 12.5% to 27.3%, P = 0.17) and the high risk group (from 78.6% to 80.8%, P = 0.73).
In this study setting, the ICT-TB test did not enhance TB diagnosis over the four clinical predictors in the overall group or any subgroups of HIV patients classified by clinical risk scores.
PMCID: PMC3191113  PMID: 22003307
diagnostic test; signs; symptoms; TB
7.  A cluster randomized trial of provider-initiated (Opt-out) HIV counseling and testing of tuberculosis patients in South Africa 
To determine whether implementation of provider-initiated HIV counseling would increase the proportion of tuberculosis patients that received HIV counseling and testing.
Cluster-randomized trial with clinic as unit of randomization
Twenty, medium-sized primary care TB clinics in the Nelson Mandela Metropolitan Municipality, Port Elizabeth, Eastern Cape Province, South Africa
A total of 754 adults (≥ 18 years) newly registered as tuberculosis patients the twenty study clinics
Implementation of provider-initiated HIV counseling and testing.
Main outcome measures
Percentage of TB patients HIV counseled and tested.
Percentage of patients HIV test positive and percentage of those that received cotrimoxazole and who were referred for HIV care.
A total of 754 adults newly registered as tuberculosis patients were enrolled. In clinics randomly assigned to implement provider-initiated HIV counseling and testing, 20.7% (73/352) patients were counseled versus 7.7% (31/402) in the control clinics (p = 0.011), and 20.2 % (n = 71) versus 6.5% (n = 26) underwent HIV testing (p = 0.009). Of those patients counseled, 97% in the intervention clinics accepted testing versus 79% in control clinics (p =0.12). The proportion of patients identified as HIV-infected in intervention clinics was 8.5% versus 2.5% in control clinics (p=0.044). Fewer than 40% of patients with a positive HIV test were prescribed cotrimoxazole or referred for HIV care in either study arm.
Provider-initiated HIV counseling significantly increased the proportion of adult TB patients that received HIV counseling and testing, but the magnitude of the effect was small. Additional interventions to optimize HIV testing for TB patients urgently need to be evaluated.
PMCID: PMC2632747  PMID: 18520677
HIV; HIV counseling and testing; tuberculosis (TB); primary care clinics; South Africa; cluster randomized trial
8.  Tuberculosis patients' reasons for, and suggestions to address non-uptake of HIV testing: a cross-sectional study in the Free State Province, South Africa 
South Africa endorses the global policy shift from primarily client-initiated voluntary counselling and testing (VCT) to routine/provider-initiated testing and counselling (PITC). The reason for this policy shift has been to facilitate uptake of HIV testing amongst at-risk populations in high-prevalence settings. Despite ostensible implementation of routine/PITC, uptake amongst tuberculosis (TB) patients in this country remains a challenge. This study presents the reasons that non-tested TB patients offered for their refusal of HIV testing and reflects on all TB patients' suggestions as to how this situation may be alleviated.
In February-March 2008, a cross-sectional survey was conducted amongst 600 TB patients across 61 primary health care facilities in four sub-districts in the Free State. Patient selection was done proportionally to the numbers registered at each facility in 2007. Data were subjected to bivariate tests and content analysis of open-ended questions.
Almost one-third (32.5%) of the respondents reported that they had not undertaken HIV testing, with the most often offered explanation being that they were 'undecided' (37.0%). Other self-reported reasons for non-uptake included: fear (e.g. of testing HIV-positive, 19.0%); perception of being at low risk of HIV infection (13.4%); desire first to deal with TB 'on its own' (12.5%); and because HIV testing had not been offered to them (12.0%). Many patients expressed the need for support and motivation not only from health care workers (33.3%), but also from their significant others (56.6%). Patients further expressed a need for (increased) dissemination of TB-HIV information by health care workers (46.1%).
Patients did not undergo HIV testing for various patient-/individual-related reasons. Non-uptake of HIV testing was also due to health system limitations such as the non-offer of HIV testing. Other measures may be necessary to supplement routine/provider-initiation of HIV testing. From the TB patient's perspective, there is a need for (improved) dissemination of information on the TB-HIV link. Patients also require (repeated) motivation and support to undergo HIV testing, the onus for which rests not only on the public health authority and health care workers, but also on other people in the patients' social support networks.
PMCID: PMC3112395  PMID: 21599883
9.  FSWs Typology and Condoms Use Among HIV High Risk Groups in Sindh, Pakistan: A Developing Country Perspective 
We aimed to determine the association of FSWs typology with condom use among HIV high risk groups in Sindh, Pakistan
HIV is growing rapidly worldwide resulting in estimated 34 million population [1]. Recently, its epidemic has spread in Africa, Latin America, and the Caribbean, and most parts of Asia [2]. According to Antenatal sero surveillance study conducted in 2011 by Agriteam canada, it’s prevalence in Pakistan is <0.1 [3].Focusing narrowly, its prevalence in Sindh, (one of the provinces of Pakistan) is similar in general population, but it is in the phase of concentrated epidemic (having more than 5% of prevalence in high risk groups)in vulnerable groups like IDUs and Male sex workers and transgender [4].
Sexual intercourse has been identified as major route especially in HIV high risk groups including male sex workers, female sex workers (FSWs), transgender (hijras) and IV drug users. Among them, FSWs are at high risk because of unprotected sex and illicit drug use. Their prevalence is found to be 30.7% in low and middle income countries [5]. South Asia contributed with 12.63 lakh FSW in India only [6]. On the basis of their station of work, they are categorized into facility based (kothikhana, brothel or home) and mobile (street, mobile or beggars). They use different preventive measures including condom for their protection from HIV [7]. It varies with availability and access [8] . FSWs typology have different cliental and mode of action, therefore, it important to explore the preventive methods.
Data was extracted from Second Generation Surveillance, Integrated behavioral and biological survey, Round IV for HIV infection conducted by Agriteam Canada in partnership with National AIDS Control Program, Pakistan in 2011. It was a cross sectional survey for high risk groups including FSWs from Pakistan. It was ethically approved by Review Board of the Public Health Agency of Canada and HOPE International’s Ethical Review Board, Pakistan. From Sindh province, FSWs based in Karachi, Sukkur and Larkana were recruited. Considering typology, they were categorized as mobile or facility based. After informed consent, socio-demographic and risk behavior were inquired. HIV was tested by ELISA/EIA and confirmed by Western Blot. Data was analyzed on SPSS 19. Continuous variables were expressed as mean±SD while categorical as frequency(%). Logistic regression assessed the association of FSWs typology with condoms use among HIV high risk groups.
Out of 4567 high risk population, 1127 were identified as FSWs. Mean age was 26.9 years. Most of them were facility based (72.8%) and 81.3% used condoms. Typology, age, education, duration of involvement, number of client per day, number of paid oral sex per month, knowledge about STI and knowledge about drop in center were significantly associated with condom use among HIV high risk groups.
Majority of facility based FSWs use condoms to prevent HIV infection. Awareness and access to home based FSWs should be increased. It may help in targeting and designing preventive strategies for them at government and mass level.
PMCID: PMC3692789
FSW; typology; condoms; HIV high risk groups; Pakistan
10.  Tuberculosis lymphadenitis in Southwest Ethiopia: a community based cross-sectional study 
BMC Public Health  2012;12:504.
In Ethiopia where there is no strong surveillance system and diagnostic facilities are limited, the real burden of tuberculosis (TB) lymphadenitis is not well known. Therefore, we conducted a study to estimate the prevalence of TB lymphadenitis in Southwest Ethiopia.
A community based cross-sectional study was conducted from February to March 2009 in the Gilgel Gibe field research area. A total of 30,040 individuals 15 years or older in 10,882 households were screened for TB lymphadenitis. Any individual 15 years or older with lumps in the neck, armpits or groin up on interview were considered TB lymphadenitis suspect. The diagnosis of TB lymphadenitis was established when acid fast bacilli (AFB) smear microscopy of fine needle aspiration (FNA) sample, culture or cytology suggested TB. HIV counseling and testing was offered to all TB lymphadenitis suspects. Descriptive and bivariate analysis was done using SPSS version 15.
Complete data were available for 27,597 individuals. A total of 87 TB lymphadenitis suspects were identified. Most of the TB lymphadenitis suspects were females (72.4%). Sixteen cases of TB lymphadenitis were confirmed. The prevalence of TB lymphadenitis was thus 58.0 per 100,000 people (16/27,597) (95% CI 35.7-94.2). Individuals who had a contact history with chronic coughers (OR 5.58, 95% CI 1.23-25.43) were more likely to have TB lymphadenitis. Lymph nodes with caseous FNA were more likely to be positive for TB lymphadenitis (OR 5.46, 95% CI 1.69-17.61).
The prevalence of TB lymphadenitis in Gilgel Gibe is similar with the WHO estimates for Ethiopia. Screening of TB lymphadenitis particularly for family members who have contact with chronic coughers is recommended. Health extension workers could be trained to screen and refer TB lymphadenitis suspects using simple methods.
PMCID: PMC3418151  PMID: 22770435
TB lymphadenitis; Prevalence; Jimma; Ethiopia
11.  Assessing the accessibility of HIV care packages among tuberculosis patients in the Northwest Region, Cameroon 
BMC Public Health  2010;10:129.
Tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection is a major source of morbidity and mortality globally. The World Health Organization (WHO) has recommended that HIV counselling and testing be offered routinely to TB patients in order to increase access to HIV care packages. We assessed the uptake of provider-initiated testing and counselling (PITC), antiretroviral (ART) and co-trimoxazole preventive therapies (CPT) among TB patients in the Northwest Region, Cameroon.
A retrospective cohort study using TB registers in 4 TB/HIV treatment centres (1 public and 3 faith-based) for patients diagnosed with TB between January 2006 and December 2007 to identify predictors of the outcomes; HIV testing/serostatus, ART and CPT enrolment and factors that influenced their enrolment between public and faith-based hospitals.
A total of 2270 TB patients were registered and offered pre-HIV test counselling; 2150 (94.7%) accepted the offer of a test. The rate of acceptance was significantly higher among patients in the public hospital compared to those in the faith-based hospitals (crude OR 1.97; 95% CI 1.33 - 2.92) and (adjusted OR 1.92; 95% CI 1.24 - 2.97). HIV prevalence was 68.5% (1473/2150). Independent predictors of HIV-seropositivity emerged as: females, age groups 15-29, 30-44 and 45-59 years, rural residence, previously treated TB and smear-negative pulmonary TB. ART uptake was 50.3% (614/1220) with 17.2% (253/1473) of missing records. Independent predictors of ART uptake were: previously treated TB and extra pulmonary TB. Finally, CPT uptake was 47.0% (524/1114) with 24% (590/1114) of missing records. Independent predictors of CPT uptake were: faith-based hospitals and female sex.
PITC services are apparently well integrated into the TB programme as demonstrated by the high testing rate. The main challenges include improving access to ART and CPT among TB patients and proper reporting and monitoring of programme activities.
PMCID: PMC2847979  PMID: 20226022
12.  Predictors of Non-Uptake of Human Immunodeficiency Virus Testing by Tuberculosis Public Primary Patients in Three Districts, South Africa 
Iranian Journal of Public Health  2012;41(11):19-26.
The acceptance of HIV testing among patients with tuberculosis (TB) is low in South Africa. The aim of this study was to assess the prevalence, associated factors and reasons of non-uptake of human immunodeficiency virus (HIV) testing by tuberculosis public primary care patients in three districts, South Africa.
In May–October 2011, this cross-sectional survey was conducted amongst 4726 TB patients across 42 primary health care facilities in three districts in South Africa. All new TB and new retreatment patients (N=4726) were consecutively interviewed within one month of anti-tuberculosis treatment. The outcome was self-reported HIV testing after TB diagnosis, validated using clinic registers.
Almost one in ten (9.6%) of the 4726 participants had not undergone HIV testing, with the most often offered explanation being that they were not knowing where to get tested (21.3%), followed by believing not to have or at risk for HIV (24.3%), emotional concerns (not ready for test: 13.2%; afraid to get to know: 12.1%; concerns over confidentiality: 6.3%) and concerns about stigma (3.3%) and losing the job (2.0%). In multivariable analysis being male, severe psychological distress, having sex with someone HIV negative or unknown and frequency of sex without a condom were associated with not having been tested for HIV.
The level of HIV testing among TB public primary care patients was suboptimal, as per policy all patients should be tested. The South African Department of Health should continue to scale-up HIV testing and other collaborative TB-HIV services at health facilities.
PMCID: PMC3521882  PMID: 23304672
HIV testing; Predictors; Tuberculosis patients; South Africa
13.  Missed opportunity for standardized diagnosis and treatment among adult Tuberculosis patients in hospitals involved in Public-Private Mix for Directly Observed Treatment Short-Course strategy in Indonesia: a cross-sectional study 
The engagement of hospitals in Public-Private Mix (PPM) for Directly Observed Treatment Short-Course (DOTS) strategy has increased rapidly internationally - including in Indonesia. In view of the rapid global scaling-up of hospital engagement, we aimed to estimate the proportion of outpatient adult Tuberculosis patients who received standardized diagnosis and treatment at outpatients units of hospitals involved in the PPM-DOTS strategy.
A cross-sectional study using morbidity reports for outpatients, laboratory registers and Tuberculosis patient registers from 1 January 2005 to 31 December 2005. By quota sampling, 62 hospitals were selected. Post-stratification analysis was conducted to estimate the proportion of Tuberculosis cases receiving standardized management according to the DOTS strategy.
Nineteen to 53% of Tuberculosis cases and 4-18% of sputum smear positive Tuberculosis cases in hospitals that participated in the PPM-DOTS strategy were not treated with standardized diagnosis and treatment as in DOTS.
This study found that a substantial proportion of TB patients cared for at PPM-DOTS hospitals are not managed under the DOTS strategy. This represents a missed opportunity for standardized diagnoses and treatment. A combination of strong individual commitment of health professionals, organizational supports, leadership, and relevant policy in hospital and National Tuberculosis Programme may be required to strengthen DOTS implementation in hospitals.
PMCID: PMC2881058  PMID: 20459665
14.  Impact of Social Franchising on Contraceptive Use When Complemented by Vouchers: A Quasi-Experimental Study in Rural Pakistan 
PLoS ONE  2013;8(9):e74260.
Pakistan has had a low contraceptive prevalence rate for the last two decades; with preference for natural birth spacing methods and condoms. Family planning services offered by the public sector have never fulfilled the demand for contraception, particularly in rural areas. In the private sector, cost is a major constraint. In 2008, Marie Stopes Society – a local NGO started a social franchise programme along with a free voucher scheme to promote uptake of IUCDs amongst the poor. This paper evaluates the effectiveness of this approach, which is designed to increase modern long term contraceptive awareness and use in rural areas of Pakistan.
We used a quasi-experimental study design with controls, selecting one intervention district and one control district from the Sindh and Punjab provinces. In each district, we chose a total of four service providers. A baseline survey was carried out among 4,992 married women of reproductive age (MWRA) in February 2009. Eighteen months after the start of intervention, an independent endline survey was conducted among 4,003 women. We used multilevel logistic regression for analysis using Stata 11.
Social franchising used alongside free vouchers for long term contraceptive choices significantly increased the awareness of modern contraception. Awareness increased by 5% in the intervention district. Similarly, the ever use of modern contraceptive increased by 28.5%, and the overall contraceptive prevalence rate increased by 19.6%. A significant change (11.1%) was recorded in the uptake of IUCDs, which were being promoted with vouchers.
Family planning franchise model promotes awareness and uptake of contraceptives. Moreover, supplemented with vouchers, it may enhance the use of IUCDs, which have a significant cost attached. Our research also supports a multi-pronged approach- generating demand through counselling, overcoming financial constraints by offering vouchers, training, accreditation and branding of the service providers, and ensuring uninterrupted contraceptive supplies.
PMCID: PMC3772094  PMID: 24069287
15.  Poverty and blindness in Pakistan: results from the Pakistan national blindness and visual impairment survey 
BMJ : British Medical Journal  2007;336(7634):29-32.
Objective To explore the association between blindness and deprivation in a nationally representative sample of adults in Pakistan.
Design Cross sectional population based survey.
Setting 221 rural and urban clusters selected randomly throughout Pakistan.
Participants Nationally representative sample of 16 507 adults aged 30 or above (95.3% response rate).
Main outcome measures Associations between visual impairment and poverty assessed by a cluster level deprivation index and a household level poverty indicator; prevalence and causes of blindness; measures of the rate of uptake and quality of eye care services.
Results 561 blind participants (<3/60 in the better eye) were identified during the survey. Clusters in urban Sindh province were the most affluent, whereas rural areas in Balochistan were the poorest. The prevalence of blindness in adults living in affluent clusters was 2.2%, compared with 3.7% in medium clusters and 3.9% in poor clusters (P<0.001 for affluent v poor). The highest prevalence of blindness was found in rural Balochistan (5.2%). The prevalence of total blindness (bilateral no light perception) was more than three times higher in poor clusters than in affluent clusters (0.24% v 0.07%, P<0.001). The prevalences of blindness caused by cataract, glaucoma, and corneal opacity were lower in affluent clusters and households. Reflecting access to eye care services, cataract surgical coverage was higher in affluent clusters (80.6%) than in medium (76.8%) and poor areas (75.1%). Intraocular lens implantation rates were significantly lower in participants from poorer households. 10.2% of adults living in affluent clusters presented to the examination station wearing spectacles, compared with 6.7% in medium clusters and 4.4% in poor cluster areas. Spectacle coverage in affluent areas was more than double that in poor clusters (23.5% v 11.1%, P<0.001).
Conclusion Blindness is associated with poverty in Pakistan; lower access to eye care services was one contributory factor. To reduce blindness, strategies targeting poor people will be needed. These interventions may have an impact on deprivation in Pakistan.
PMCID: PMC2174750  PMID: 18087076
16.  Community-Based Rapid Oral Human Immunodeficiency Virus Testing for Tuberculosis Patients in Lima, Peru 
Among tuberculosis patients, timely diagnosis of human immunodeficiency virus (HIV) co-infection and early antiretroviral treatment are crucial, but are hampered by a myriad of individual and structural barriers. Community-based models to provide counseling and rapid HIV testing are few but offer promise. During November 2009–April 2010, community health workers offered and performed HIV counseling and testing by using the OraQuick Rapid HIV-1/2 Antibody Test to new tuberculosis cases in 22 Ministry of Health establishments and their household contacts (n = 130) in Lima, Peru. Refusal of HIV testing or study participation was low (4.7%). Intervention strengths included community-based approach with participant preference for testing site, use of a rapid, non-invasive test, and accompaniment to facilitate HIV care and family disclosure. We will expand the intervention under programmatic auspices for rapid community-based testing for new tuberculosis cases in high incidence establishments. Other potential target populations include contacts of HIV-positive persons and pregnant women.
PMCID: PMC3435339  PMID: 22826481
17.  Undiagnosed Tuberculosis in a Community with High HIV Prevalence 
Background: Although failure of tuberculosis (TB) control in sub-Saharan Africa is attributed to the HIV epidemic, it is unclear why the directly observed therapy short-course (DOTS) strategy is insufficient in this setting. We conducted a cross-sectional survey of pulmonary TB (PTB) and HIV infection in a community of 13,000 with high HIV prevalence and high TB notification rate and a well-functioning DOTS TB control program.
Methods: Active case finding for PTB was performed in 762 adults using sputum microscopy and Mycobacterium tuberculosis culture, testing for HIV, and a symptom and risk factor questionnaire. Survey findings were correlated with notification data extracted from the TB treatment register.
Results: Of those surveyed, 174 (23%) tested HIV positive, 11 (7 HIV positive) were receiving TB therapy, 6 (5 HIV positive) had previously undiagnosed smear-positive PTB, and 6 (4 HIV positive) had smear-negative/culture-positive PTB. Symptoms were not a useful screen for PTB. Among HIV-positive and -negative individuals, prevalence of notified smear-positive PTB was 1,563/100,000 and 352/100,000, undiagnosed smear-positive PTB prevalence was 2,837/100,000 and 175/100,000, and case-finding proportions were 37 and 67%, respectively. Estimated duration of infectiousness was similar for HIV-positive and HIV-negative individuals. However, 87% of total person-years of undiagnosed smear-positive TB in the community were among HIV-infected individuals.
Conclusions: PTB was identified in 9% of HIV-infected individuals, with 5% being previously undiagnosed. Lack of symptoms suggestive of PTB may contribute to low case-finding rates. DOTS strategy based on passive case finding should be supplemented by active case finding targeting HIV-infected individuals.
PMCID: PMC1899262  PMID: 16973982
African community; case finding; HIV infection; incidence and prevalence; pulmonary tuberculosis
18.  Sputum smear negative pulmonary tuberculosis: sensitivity and specificity of diagnostic algorithm 
BMC Research Notes  2011;4:475.
The diagnosis of pulmonary tuberculosis in patients with Human Immunodeficiency Virus (HIV) is complicated by the increased presence of sputum smear negative tuberculosis. Diagnosis of smear negative pulmonary tuberculosis is made by an algorithm recommended by the National Tuberculosis and Leprosy Programme that uses symptoms, signs and laboratory results.
The objective of this study is to determine the sensitivity and specificity of the tuberculosis treatment algorithm used for the diagnosis of sputum smear negative pulmonary tuberculosis.
A cross-section study with prospective enrollment of patients was conducted in Dar-es-Salaam Tanzania. For patients with sputum smear negative, sputum was sent for culture. All consenting recruited patients were counseled and tested for HIV. Patients were evaluated using the National Tuberculosis and Leprosy Programme guidelines and those fulfilling the criteria of having active pulmonary tuberculosis were started on anti tuberculosis therapy. Remaining patients were provided appropriate therapy. A chest X-ray, mantoux test, and Full Blood Picture were done for each patient. The sensitivity and specificity of the recommended algorithm was calculated. Predictors of sputum culture positive were determined using multivariate analysis.
During the study, 467 subjects were enrolled. Of those, 318 (68.1%) were HIV positive, 127 (27.2%) had sputum culture positive for Mycobacteria Tuberculosis, of whom 66 (51.9%) were correctly treated with anti-Tuberculosis drugs and 61 (48.1%) were missed and did not get anti-Tuberculosis drugs. Of the 286 subjects with sputum culture negative, 107 (37.4%) were incorrectly treated with anti-Tuberculosis drugs. The diagnostic algorithm for smear negative pulmonary tuberculosis had a sensitivity and specificity of 38.1% and 74.5% respectively. The presence of a dry cough, a high respiratory rate, a low eosinophil count, a mixed type of anaemia and presence of a cavity were found to be predictive of smear negative but culture positive pulmonary tuberculosis.
The current practices of establishing pulmonary tuberculosis diagnosis are not sensitive and specific enough to establish the diagnosis of Acid Fast Bacilli smear negative pulmonary tuberculosis and over treat people with no pulmonary tuberculosis.
PMCID: PMC3216301  PMID: 22044882
Sputum smear negative; Human Immunodeficiency Virus; Symptoms
19.  Current Integration of Tuberculosis (TB) and HIV Services in South Africa, 2011 
PLoS ONE  2013;8(3):e57791.
Public Health Facilities in South Africa.
To assess the current integration of TB and HIV services in South Africa, 2011.
Cross-sectional study of 49 randomly selected health facilities in South Africa. Trained interviewers administered a standardized questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. We calculated and compared descriptive statistics by province and facility type.
Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to Tb clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centers (p<0.001).
As of February 2011, integration of TB and HIV services is taking place in public medical facilities in South Africa. Among these services, IPT in people living with HIV and ART in TB patients are the least available.
PMCID: PMC3587619  PMID: 23469242
20.  Prevalence of drug resistance associated mutations in Plasmodium vivax against sulphadoxine-pyrimethamine in southern Pakistan 
Malaria Journal  2013;12:261.
In Pakistan, Plasmodium vivax and Plasmodium falciparum co-exist and usage of sulphadoxine-pyrimethamine (SP) against P. falciparum exposes P. vivax to the drug leading to generation of resistant alleles. The main aim of this study was to investigate frequency distribution of drug resistance associated mutations in pvdhfr, pvdhps genes and provide baseline molecular epidemiological data on SP-associated resistance in P. vivax from southern Pakistan.
From January 2008 to May 2009, a total of 150 samples were collected from patients tested slide-positive for P. vivax, at the Aga Khan University Hospital, Karachi, or its collection units located in Baluchistan and Sindh Province. Nested PCR using pvdhfr and pvdhps specific primers was performed for all samples.91.3% (137/150) of the samples were tested PCR positive of which 87.3% (131/137) were successfully sequenced. Sample sequencing data was analysed and compared against wild type reference sequences.
In dhfr, mutations were observed at codons F57L, S58R and S117N/T. Novel non-synonymous mutations were observed at codon positions N50I, G114R and E119K while a synonymous mutation was observed at codon position 69Y. In dhps, mutations were observed at codon position A383G and A553G while novel non-synonymous mutations were observed at codon positions S373T, E380K, P384L, N389T, V392D, T393P, D459A, M601I, A651D and A661V.
This is the first report from southern Pakistan on SP resistance in clinical isolates of P. vivax. Results from this study confirm that diverse drug resistant alleles are circulating within this region.
PMCID: PMC3733603  PMID: 23890361
Plasmodium vivax; Pakistan; Dihydrofolate reductase; Dihydroptereoate synthase; Single nucleotide polymorphisms
21.  Genetic diversity of Plasmodium vivax clinical isolates from southern Pakistan using pvcsp and pvmsp1 genetic markers 
Malaria Journal  2013;12:16.
Plasmodium vivax is the prevalent malarial species accounting for 70% of malaria burden in Pakistan; however, there is no baseline data on the circulating genotypes. Studies have shown that polymorphic loci of gene encoding antigens pvcsp and pvmsp1 can be used reliably for conducting molecular epidemiological studies. Therefore, this study aimed to bridge the existing knowledge gap on population structure on P. vivax from Pakistan using these two polymorphic genes.
During the period January 2008 to May 2009, a total of 250 blood samples were collected from patients tested slide positive for P. vivax, at the Aga Khan University Hospital, Karachi, or its collection units located in Baluchistan and Sindh Province. Nested PCR/RFLP was performed, using pvcsp and pvmsp1 markers to detect the extent of genetic diversity in clinical isolates of P. vivax from southern Pakistan.
A total of 227/250 (91%) isolates were included in the analysis while the remainder were excluded due to negative PCR outcome for P.vivax. Pvcsp analysis showed that both VK 210 (85.5%, 194/227) and VK 247 type (14.5%, 33/227) were found to be circulating in P. vivax isolates from southern Pakistan. A total of sixteen and eighty-seven genotypes of pvcsp and pvmsp-1 were detected respectively.
This is the first report from southern Pakistan on characterization of P. vivax isolates confirming that extensively diverse pvcsp and pvmsp1 variants are present within this region. Results from this study provide valuable data on genetic diversity of P. vivax that will be helpful for further epidemiological studies.
PMCID: PMC3601996  PMID: 23311628
Malaria; Plasmodium vivax; Pakistan; Genetic diversity; Population structure; Circumsporozoite protein; Merozoite surface protein 1
22.  Prevalence and Predictors of HIV among Chinese Tuberculosis Patients by Provider-Initiated HIV Testing and Counselling (PITC): A Multisite Study in South Central of China 
PLoS ONE  2014;9(2):e89723.
Tuberculosis (TB) and HIV are two worldwide public health concerns. Co-infection of these two diseases has been considered to be a major obstacle for the global efforts in reaching the goals for the prevention of HIV and TB.
A comprehensive cross-sectional study was conducted to recruit TB patients in three provinces (Guangxi, Henan and Sichuan) of China between April 1 and September 30, 2010.
A total of 1,032 consenting TB patients attended this survey during the study period. Among the participants, 3.30% were HIV positive; about one quarter had opportunistic infections. Nearly half of the participants were 50 years or older, the majority were male and about one third were from minority ethnic groups. After adjusting for site, gender and areas of residence (using the partial/selective Model 1), former commercial plasma donors (adjusted OR [aOR] = 33.71) and injecting drug users(aOR = 15.86) were found to have significantly higher risk of being HIV-positivity. In addition, having extramarital sexual relationship (aOR = 307.16), being engaged in commercial sex (aOR = 252.37), suffering from opportunistic infections in the past six months (aOR = 2.79), losing 10% or more of the body weight in the past six months (aOR = 5.90) and having abnormal chest X-ray findings (aOR = 20.40) were all significantly associated with HIV seropositivity (each p<0.05).
HIV prevalence among TB patients was high in the study areas of China. To control the dual epidemic, intervention strategies targeting socio-demographic and behavioral factors associated with higher risk of TB-HIV co-infection are urgently called for.
PMCID: PMC3931821  PMID: 24586987
23.  Are routine tuberculosis programme data suitable to report on antiretroviral therapy use of HIV-infected tuberculosis patients? 
BMC Research Notes  2013;6:23.
Antiretroviral therapy (ART) is lifesaving for HIV-infected tuberculosis (TB) patients. ART-use by these patients lag behind compared to HIV-testing and co-trimoxazole preventive therapy. TB programmes provide the data on ART-use by HIV-infected TB patients, however often the HIV services provide the ART. We evaluated whether the data on ART-use in the TB register were complete and correct. The timing of ART initiation was evaluated to assess whether reporting on ART-use could have happened with the TB case finding reporting. We collected data on TB treatment, HIV testing and ART for adult TB cases in 2007 from three TB clinics in Manica Province, Mozambique. These data on use of ART from TB registers were compared with those from the HIV services.
Of 628 patients included, 504 (81%) were tested and of these 356 (71%) were HIV-infected. Of the co-infected patients, 81% registered with the HIV services in the same facility. The TB register was correct on ART-use in 73% of co-infected cases and complete in 74%. Information on ART-use could have been reported with the TB case finding reports in 56% of co-infected patients.
The TB register is reasonably correct and complete on ART-use. However, the HIV patient record seems a much better source to provide this information. Reporting on ART-use at the end of the quarter in which TB treatment starts provides the programme with timely but incomplete information. A more complete but less timely picture is available after a year.
PMCID: PMC3556319  PMID: 23331952
Africa; Routine programme data; Tuberculosis; HIV
24.  Knowledge about HIV prevention and transmission among recently diagnosed tuberculosis patients: a cross sectional study 
BMC Public Health  2013;13:1237.
Patients with Tuberculosis (TB) are a vulnerable group for acquiring HIV infection. Therefore, countries with a concentrated HIV epidemic and high prevalence of TB should provide adequate information about HIV prevention to TB patients.
We conducted a cross-sectional study to evaluate the level of knowledge on HIV prevention and transmission among newly diagnosed TB patients in Lima, Peru. The survey evaluated knowledge about HIV infection and prevention and was administered before HIV counseling and blood sampling for HIV testing were performed.
A total of 171 TB patients were enrolled; mean age was 31.1 years, 101 (59%) were male. The overall mean level of knowledge of HIV was 59%; but the specific mean level of knowledge on HIV transmission and prevention was only 33.3% and 41.5%, respectively. Age and level of education correlated with overall level of knowledge in the multivariate model (P-value: 0.02 and <0.001 respectively).
The study shows inadequate levels of knowledge about HIV transmission and prevention among newly-diagnosed TB patients in this setting, and underscores the need for implementing educational interventions in this population.
PMCID: PMC3883486  PMID: 24373517
HIV; Tuberculosis; Knowledge; Prevention
25.  High Diabetes Prevalence among Tuberculosis Cases in Kerala, India 
PLoS ONE  2012;7(10):e46502.
While diabetes mellitus (DM) is a known risk factor for tuberculosis, the prevalence among TB patients in India is unknown. Routine screening of TB patients for DM may be an opportunity for its early diagnosis and improved management and might improve TB treatment outcomes. We conducted a cross-sectional survey of TB patients registered from June–July 2011 in the state of Kerala, India, to determine the prevalence of DM.
Methodology/Principal Findings
A state-wide representative sample of TB patients in Kerala was interviewed and screened for DM using glycosylated hemoglobin (HbA1c); patients self-reporting a history of DM or those with HbA1c ≥6.5% were defined as diabetic. Among 552 TB patients screened, 243(44%) had DM – 128(23%) had previously known DM and 115(21%) were newly diagnosed - with higher prevalence among males and those aged >50years. The number needed to screen(NNS) to find one newly diagnosed case of DM was just four. Of 128 TB patients with previously known DM, 107(84%) had HbA1c ≥7% indicating poor glycemic control.
Nearly half of TB patients in Kerala have DM, and approximately half of these patients were newly-diagnosed during this survey. Routine screening of TB patients for DM using HbA1c yielded a large number of DM cases and offered earlier management opportunities which may improve TB and DM outcomes. However, the most cost-effective ways of DM screening need to be established by futher operational research.
PMCID: PMC3471898  PMID: 23077512

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