Date of Award


Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

First Advisor

Lloyd Cantley

Second Advisor

Gerald Friedland


ABSTRACT High Rates of Undiagnosed Pulmonary Tuberculosis and Barriers to Diagnosis and Care Among HIV-positive Patients in a Rural South African Hospital: A Cross-sectional cohort study Palav A. Babaria, N. Sarita Shah, Anthony P. Moll, Neel R. Gandhi, Gerald H. Friedland. Yale AIDS Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT. Tuberculosis (TB) is the leading cause of mortality among HIV infected patients in South Africa. Symptoms of active TB may be subtle in HIV patients and go unrecognized in early illness, creating an opportunity for nosocomial TB transmission. Late presentation and delayed diagnosis of TB also contribute to increased mortality and community-based TB transmission. In an effort to identify active TB promptly, screening for TB must be integrated into routine HIV care and barriers to seeking care must be addressed. We prospectively initiated a standardized TB screening program at a rural HIV clinic to determine the prevalence of unsuspected TB and drug-resistant TB. All HIV clinic patients at a rural hospital in Tugela Ferry, South Africa were screened for TB symptom and those with one or more TB symptoms (e.g., cough, night sweats, fever) were enrolled and submitted sputum samples for microscopy, mycobacterial culture and drug-susceptibility testing (DST). We also administered a questionnaire to all inpatient and outpatient participants based on the Information, Motivation, and Behavioral Skills (IMB) model in order to identify barriers to TB diagnosis and care. Among 263 HIV-infected ambulatory patients enrolled, 52 (20%) were culture-positive for TB and 24 (9%) were smear-positive. Among 46 patients with available DST results, 13 (5% of 263 screened) were resistant to at least isoniazid and rifampin (MDR TB); and 7 of these (3%) met criteria for XDR TB. Patients with TB were more likely to be male (p=.01), without a prior history of TB (p=.02), and had lower median CD4 counts (p<0.001). Patients presented with similar symptoms irrespective of TB status, except for weight loss, which was significantly greater among those with TB. Twenty seven percent of all patients reported delaying seeking care for >4 weeks. Delay was associated with male gender (p=0.02), not on ARVs (p<0.001), and being seen elsewhere for treatment (p=0.003). Among 480 patients who completed the IMB questionnaire, 387 (81%) thought TB was treatable and 231 (48%) thought that having TB meant you also had HIV. Almost all felt that they could disclose their TB (97%) or HIV (88%) status to a family member. However, several barriers to seeking care were identified: 294 (61%) stated they lived too far to be treated and 263 (55%) lacked finances for transport to the hospital. This study demonstrates a high prevalence of active TB, particularly MDR & XDR TB, among HIV clinic patients in rural South Africa. These unrecognized TB cases raise concern for nosocomial TB transmission among vulnerable HIV patients and underscore the need for active TB case finding and infection control measures. The majority of patients also identified barriers for accessing care, including distance to hospital and lack of transport money. These findings support further strengthening of TB and HIV programs, particularly decentralized TB screening and care.