Eye examination for early diagnosis of disseminated tuberculosis in patients with AIDS.

Choroidal tuberculosis is present in 5-20% of patients with disseminated tuberculosis, and point-of-care dilated binocular indirect ophthalmoscopy eye examination can provide immediate diagnosis. In geographical areas of high tuberculosis prevalence and in susceptible patients (CD4 counts less than 200 cells per μL) detection of choroidal granulomas should be accepted as evidence of disseminated tuberculosis. With training and proper support, eye screening can be done by HIV/AIDS clinicians, allowing early tuberculosis treatment.

Implementing the Xpert® MTB/RIF Diagnostic Test for Tuberculosis and Rifampicin Resistance: Outcomes and Lessons Learned in 18 Countries.

Background: The Xpert® MTB/RIF (Xpert) is an automated molecular test for simultaneous detection of tuberculosis (TB) and rifampicin resistance, recommended by the World Health Organization as the preferred diagnostic method for individuals presumed to have multi-drug resistant TB (MDR-TB) or HIV-associated TB. We describe the performance of Xpert and key lessons learned during two years of implementation under routine conditions in 33 projects located in 18 countries supported by Médecins Sans Frontières across varied geographic, epidemiological and clinical settings.

Methods: Xpert was used following three strategies: the first being as the initial test, with microscopy in parallel, for all presumptive TB cases; the second being only for patients at risk of MDR-TB, or with HIV- associated TB, or presumptive paediatric TB; and the third being as the initial test for these high-risk patients plus as an add-on test to microscopy in others.

Double trouble: tuberculosis and substance abuse in Nagaland, India.

The diagnosis and treatment of tuberculosis (TB) in people who use and/or inject illicit drugs (PWUIDs) remains a barrier to achieving universal coverage for TB in India and globally. This report describes treatment outcomes in PWUIDs who received treatment for drug-susceptible TB at the Mon District Hospital in Nagaland, India, during 2012-2013. The median age of the patients was 39 years, and most (92%) were male.

Resistance patterns among multidrug-resistant tuberculosis patients in greater metropolitan Mumbai: trends over time.

Background: While the high burden of multidrug-resistant tuberculosis (MDR-TB) itself is a matter of great concern, the emergence and rise of advanced forms of drug-resistance such as extensively drug-resistant TB (XDR-TB) and extremely drug-resistant TB (XXDR-TB) is more troubling. The aim of this study was to investigate the trends over time of patterns of drug resistance in a sample of MDR-TB patients in greater metropolitan Mumbai, India.

Methods: This was a retrospective, observational study of drug susceptibility testing (DST) results among MDR-TB patients from eight health care facilities in greater Mumbai between 2005 and 2013.

Training clinicians treating HIV to diagnose cytomegalovirus retinitis.

Problem: Acquired immunodeficiency syndrome (AIDS)-related cytomegalovirus (CMV) retinitis continues to be a neglected source of blindness in resource-poor settings. The main issue is lack of capacity to diagnose CMV retinitis in the clinical setting where patients receive care and all other opportunistic infections are diagnosed.

Approach: We developed and implemented a four-day workshop to train clinicians working in human immunodeficiency virus (HIV) clinics how to perform binocular indirect ophthalmoscopy and diagnose CMV retinitis.

Alarming levels of drug-resistant tuberculosis in HIV-infected patients in metropolitan Mumbai, India.

Background: Drug-resistant tuberculosis (DR-TB) is a looming threat to tuberculosis control in India. However, no countrywide prevalence data are available. The burden of DR-TB in HIV-co-infected patients is likewise unknown.

Self-administered tuberculosis treatment outcomes in a tribal population on the indo-myanmar border, Nagaland, India.

Background: Multiple strategies are being adopted by national tuberculosis (TB) programmes to achieve universal coverage of tuberculosis treatment. However, populations living in 'hard-to-reach' areas of north-east India have poor access to health services. Our study aimed to detail treatment outcomes in TB program supported by Médecins Sans Frontières (MSF) and using an alternative model of TB treatment delivery in Mon district, Nagaland, India.

Patch-testing for the management of hypersensitivity reactions to second-line anti-tuberculosis drugs: a case report.

Background: The second-line anti-tuberculosis drugs used in the treatment of multidrug-resistant tuberculosis often cause adverse events, especially in patients co-infected with the human immunodeficiency virus. Severe hypersensitivity reactions due to these drugs are rare and there is little published experience to guide their management.

Case Presentation: A 17-year old Indian female multidrug-resistant tuberculosis patient co-infected with human immunodeficiency virus developed a hypersensitivity reaction after starting second-line anti-tuberculosis treatment in Mumbai, India.

Second-line failure and first experience with third-line antiretroviral therapy in Mumbai, India.

Background: There are limited data on the failure of second-line antiretroviral therapy (ART) and the use of third-line ART in people living with HIV in resource-limited settings. Since 2011, the Médecins Sans Frontières (MSF) HIV/tuberculosis programme in Mumbai, India, has been providing third-line ART to patients in care.

Objective: To describe the experiences and programmatic challenges during management of suspected second-line ART failure and third-line ART therapy for patients living with HIV, including the use of HIV viral load (VL) testing.

Infection control in households of drug-resistant tuberculosis patients co-infected with HIV in Mumbai, India.

Background: Mumbai has a population of 21 million, and an increasingly recognised epidemic of drug-resistant tuberculosis (DR-TB).

Objective: To describe TB infection control (IC) measures implemented in households of DR-TB patients co-infected with the human immunodeficiency virus (HIV) under a Médecins Sans Frontières programme.

Methods: IC assessments were carried out in patient households between May 2012 and March 2013.

Barriers to pilot mobile teleophthalmology in a rural hospital in Southern Malawi.

Introduction: Malawi has one of the highest HIV prevalences in Sub-Saharan Africa. The rate of eligible HIV-infected people being initiated on antiretroviral therapy (ART) and retained in HIV-care is currently far from adequate. Consequently, many people continue present with advanced immunosuppression at public health facilities, often with undiagnosed opportunistic infections (OIs).

High rate of hypothyroidism in multidrug-resistant tuberculosis patients co-infected with HIV in Mumbai, India.

Background: Adverse events (AEs) among HIV-infected patients with multidrug-resistant tuberculosis (MDR-TB) receiving anti-TB and antiretroviral treatments (ART) are under-researched and underreported. Hypothyroidism is a common AE associated with ethionamide, p-aminosalicylic acid (PAS), and stavudine. The aim of this study was to determine the frequency of and risk factors associated with hypothyroidism in HIV/MDR-TB co-infected patients.

Feasibility and benefits of scaling up antiretroviral treatment provision with the 2010 WHO antiretroviral therapy guidelines in rural Lesotho.

The latest WHO guidelines (2010) for antiretroviral therapy (ART) in adults and adolescents recommend that countries should progressively reduce the use of stavudine in favour of tenofovir or zidovudine and that ART initiation commence at an earlier CD4 threshold of <350 cell/mm(3). In Lesotho, a high-burden, resource-limited setting, these two changes had been recommended since late 2007. A number of practical steps were taken to support implementation of Lesotho's national ART guidelines at the program level including: development of guidelines tailored to nurses working in primary care settings; training and clinical mentorship of different levels of health care workers; laboratory support; pharmacy support; and monitoring and evaluation.

Burden of HIV-related cytomegalovirus retinitis in resource-limited settings: a systematic review.

Background: Cytomegalovirus (CMV) is a late-stage opportunistic infection in people living with human immunodeficiency virus (HIV)/AIDS. Lack of ophthalmological diagnostic skills, lack of convenient CMV treatment, and increasing access to antiretroviral therapy have all contributed to an assumption that CMV retinitis is no longer a concern in low- and middle-income settings.

Methods: We conducted a systematic review and meta-analysis of published and unpublished studies reporting prevalence of CMV retinitis in low- and middle-income countries.

Poor outcomes in a cohort of HIV-infected adolescents undergoing treatment for multidrug-resistant tuberculosis in Mumbai, India.

Background: Little is known about the treatment of multidrug-resistant tuberculosis (MDR-TB) in HIV-co-infected adolescents. This study aimed to present the intermediate outcomes of HIV-infected adolescents aged 10-19 years receiving second-line anti-TB treatment in a Médecins Sans Frontières (MSF) project in Mumbai, India.

Methods: A retrospective review of medical records of 11 adolescents enrolled between July 2007 and January 2013 was undertaken.

Ocular inflammatory disease and ocular tuberculosis in a cohort of patients co-infected with HIV and multidrug-resistant tuberculosis in Mumbai, India: a cross-sectional study.

Background: The prevalence and the patterns of ocular inflammatory disease and ocular tuberculosis (TB) are largely undocumented among Multidrug Resistant TB (MDR-TB) patients co-infected with Human Immunodeficiency Virus (HIV) and on antituberculosis and antiretroviral therapy (ART).

Methods: Lilavati Hospital and Research Center and Médecins Sans Frontières (MSF) organized a cross-sectional ophthalmological evaluation of HIV/MDR-TB co-infected patients followed in an MSF-run HIV-clinic in Mumbai, India, which included measuring visual acuity, and slit lamp and dilated fundus examinations.

Results: Between February and April 2012, 47 HIV/MDR-TB co-infected patients (including three patients with extensively drug-resistant TB) were evaluated.

Adverse events among HIV/MDR-TB co-infected patients receiving antiretroviral and second line anti-TB treatment in Mumbai, India.

Background: Significant adverse events (AE) have been reported in patients receiving medications for multidrug- and extensively-drug-resistant tuberculosis (MDR-TB & XDR-TB). However, there is little prospective data on AE in MDR- or XDR-TB/HIV co-infected patients on antituberculosis and antiretroviral therapy (ART) in programmatic settings.

Methods: Médecins Sans Frontières (MSF) is supporting a community-based treatment program for drug-resistant tuberculosis in HIV-infected patients in a slum setting in Mumbai, India since 2007.

Ambulatory multi-drug resistant tuberculosis treatment outcomes in a cohort of HIV-infected patients in a slum setting in Mumbai, India.

Background: India carries one quarter of the global burden of multi-drug resistant TB (MDR-TB) and has an estimated 2.5 million people living with HIV. Despite this reality, provision of treatment for MDR-TB is extremely limited, particularly for HIV-infected individuals.