The resurgence of tuberculosis (TB) in the United States and the growing problem of multidrug- resistant TB have been linked to the HIV epidemic. Information on HIV status of all reported TB cases is necessary to accurately measure the extent of and trends in comorbidity due to HIV and Mycobacterium tuberculosis and to ensure the best provision of services to HIV-infected persons with TB. HIV counseling and antibody testing is recommended for all persons diagnosed with TB. Since 1993, HIV-status information is collected on the Report of a Verified Case of TB (RVCT) and reported to TB surveillance. However, only 36.4% and 42.3% of TB cases age 25-44 years reported in 1994 and 1995, respectively, contained HIV results.
The HIV Epidemiology Program is one of six sites funded by the Centers for Disease Control and Prevention (CDC) to evaluate HIV counseling and testing practices in patients with TB. In Los Angeles, this study is being conducted collaboratively between the TB Control Program and the HIV Epidemiology Program. There are three major components to this study: 1) health care provider survey, 2) medical record review of a sample of TB patients, between the ages of 25 and 44, who were reported to the TB Control Program in 1996, and 3) a TB/HIV education and training.
- To assess current HIV counseling and testing practices by public and private TB care providers who have reported or provided medical care to adult TB cases reported in 1996 via a health care provider survey.
- To determine whether TB patients, aged 25-44 years, a) were offered HIV counseling and testing and the results of such testing, b) were questioned about HIV risk factors, c) were referred for HIV-related services if HIV-positive, and d) had missed opportunities for HIV counseling and testing via medical record review.
- To provide a joint training session to personnel from TB and AIDS programs in local and state health departments.
The health care provider survey was a cross-sectional survey of TB-care providers in Los Angeles County. The 4-page questionnaire was designed to elicit information on the description of the medical practice; TB and AIDS reporting practices, treatment and referral practices; HIV counseling and testing practices; and barriers to HIV testing.The study population for the survey included both public and private health care providers who have reported and/or medically- managed TB cases in 1996. The public providers included 11 chest clinicians from 11 county public health centers and attending physicians in the departments of general medicine, internal medicine, infectious disease, or pulmonary from five county hospitals (LAC-USC, Harbor- UCLA, King-Drew, Olive View, and Mira Loma/High Desert). For private providers, TB case files originally reported from non-public medical sites were reviewed to find names of private providers who reported and/or medically-managed a TB case in 1996. Through our review, we found 93 providers who reported and/or medically-managed two or more TB cases in 1996 and 456 providers with one. For our study population (total=335), we included all public providers (n=119), all private providers with two or more TB cases (n=93), and 123 randomly selected private providers with one TB case in 1996.
The study subjects for the medical record review are TB cases, aged 25-44 years, who were reported to the Los Angeles County Department of Health Services TB Control Program during 1996. In 1996, there were 466 TB cases who met the aforementioned eligibility criteria. Of which, we randomly selected 60% (n=280) for the medical record review component. Two forms were developed for the medical record review (General Information Worksheet and the Medical Record Review-Core Questions). The General Information Worksheet elicits data on the month/year the TB case was reported and counted; the date therapy started; and the date the first isolate was collected. In addition, TB patient's HIV test result reported to the TB registry is collected. The Medical Record Review-Core Questions form is designed to elicit information on the patient's HIV history and laboratory status (if positive); HIV counseling and testing practices; HIV risk assessment; referrals to non-medical HIV/AIDS services; and antiretroviral medications.
A one-day conference for public providers and staff and an one-day conference for private providers will be offered in February 1999. The TB/HIV Education and Training will include the latest CDC recommendations for TB prevention and control, the reasons for collaboration between the two groups, surveillance mechanisms and definitions, the importance of and methods for maintaining confidentiality, availability of services for HIV counseling and testing, and treating HIV-infected TB patients.
Amy Wohl, Ph.D.
Mi Suk Yu, M.S.P.H.