Systematic case finding for tuberculosis in HIV-infected people who inject drugs: experience from Pakistan

Setting Pakistan is a high tuberculosis (TB) burden country, moving from low human immunodeficiency virus (HIV) prevalence to a concentrated epidemic driven primarily by people who inject drugs (PWID). The Antiretroviral Treatment Adherence Unit (AAU) in Islamabad, Pakistan, is a residential facility that offers combined treatment for opioid dependence and HIV. Objective and design This retrospective study was conducted to assess TB prevalence among HIV-infected PWID referred to the AAU and to evaluate the diagnostic value of cough as a screening symptom. A single sputum sample was collected regardless of symptoms, and examined using smear, Xpert® MTB/RIF and culture. Results Of 888 PWID, 71.5% submitted a sputum sample. More TB cases were detected using Xpert (n = 25) than with smear (n = 10) or culture (n = 20). A TB prevalence of 6141 per 100 000 was estimated based on seven cases already identified as being on anti-tuberculosis treatment and 32 newly diagnosed bacteriologically confirmed TB cases. Both cough and smoking (10 pack-years) were associated with increased TB prevalence. Only half of the TB cases reported cough. Rifampicin resistance was reported among 10% (3/29) of newly identified cases. Conclusion TB prevalence in HIV-infected PWID was 15 times higher than in the general adult population. As a screening symptom, cough has low diagnostic value.