Integrating Community-Based Interventions to Reverse the Convergent TB/HIV Epidemics in Rural South Africa.
The WHO recommends integrating interventions to address the devastating TB/HIV co-epidemics in South Africa, yet integration has been poorly implemented and TB/HIV control efforts need strengthening. Identifying infected individuals is particularly difficult in rural settings. We used mathematical modeling to predict the impact of community-based, integrated TB/HIV case finding and additional control strategies on South Africa's TB/HIV epidemics. We developed a model incorporating TB and HIV transmission to evaluate the effectiveness of integrating TB and HIV interventions in rural South Africa over 10 years. We modeled the impact of a novel screening program that integrates case finding for TB and HIV in the community, comparing it to status quo and recommended TB/HIV control strategies, including GeneXpert, MDR-TB treatment decentralization, improved first-line TB treatment cure rate, isoniazid preventive therapy, and expanded ART. Combining recommended interventions averted 27% of expected TB cases (95% CI 18-40%) 18% HIV (95% CI 13-24%), 60% MDR-TB (95% CI 34-83%), 69% XDR-TB (95% CI 34-90%), and 16% TB/HIV deaths (95% CI 12-29). Supplementing these interventions with annual community-based TB/HIV case finding averted a further 17% of TB cases (44% total; 95% CI 31-56%), 5% HIV (23% total; 95% CI 17-29%), 8% MDR-TB (68% total; 95% CI 40-88%), 4% XDR-TB (73% total; 95% CI 38-91%), and 8% TB/HIV deaths (24% total; 95% CI 16-39%). In addition to increasing screening frequency, we found that improving TB symptom questionnaire sensitivity, second-line TB treatment delays, default before initiating TB treatment or ART, and second-line TB drug efficacy were significantly associated with even greater reductions in TB and HIV cases. TB/HIV epidemics in South Africa were most effectively curtailed by simultaneously implementing interventions that integrated community-based TB/HIV control strategies and targeted drug-resistant TB. Strengthening existing TB and HIV treatment programs is needed to further reduce disease incidence.
Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States of America; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, United States of America.
Jennifer A
JA
Gilbert
Anderson School of Management, University of California Los Angeles, Los Angeles, CA, United States of America.
Elisa F
EF
Long
Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, CT, United States of America.
Ralph P
RP
Brooks
Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States of America; Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, CT, United States of America.
Gerald H
GH
Friedland
Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, CT, United States of America; Church of Scotland Hospital, Tugela Ferry, KwaZulu-Natal, South Africa.
Anthony P
AP
Moll
Department of Biostatistics, Yale University, New Haven, CT, United States of America; Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, United States of America; Program in Computational Biology and Informatics, Yale University, New Haven, CT, United States of America.
Jeffrey P
JP
Townsend
Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States of America; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, United States of America; Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, United States of America; Program in Computational Biology and Informatics, Yale University, New Haven, CT, United States of America.
Alison P
AP
Galvani
Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, CT, United States of America.
Sheela V
SV
Shenoi
D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology*; D006801:Humans; D008875:Middle Aged; D013019:South Africa / Q000453:epidemiology; D014376:Tuberculosis / Q000188:drug therapy* / Q000453:epidemiology*; D055815:Young Adult
D019380:Anti-HIV Agents; D000995:Antitubercular Agents