Ann Intern Med -- Rapid Responses for Dosanjh et al., 148 (5) 325-336

Assume Nothing About Tb and HIV.

Dear Editor,

I am grateful that Dosanjh and colleagues and others continue to troll the murky waters of tuberculosis diagnosis.¹ As the editorial asserts, how this emerging field of in vitro immunoassay diagnostics for both active and latent infection by Mycobacterium tuberculosis should be navigated is an open question.² While I read the results of the study with interest, that they had not screened for HIV infection in all of their subjects surprised me.¹ They cite a 1998 survey of tuberculosis in England and Wales for this decision, which in fairness was published shortly before initiating enrollment in 2002.³ The overall HIV co-infection rate was 3.3 per cent, 5.8 per cent in London. Even with sporadic testing (actual testing rates not provided) for HIV, Dosanjh and colleagues observed HIV-Tb co-infection rates of 5.2 per cent among culture-confirmed, and 10.3 per cent among clinically indeterminate tuberculosis patients.

According to WHO Europe Region data (http://www.euro.who.int/InformationSources/Data/20050117_3 acc. 12 March 2008), the UK may have an increasing incidence of tuberculosis, with a more dramatically increasing reported HIV incidence (table). In the same year that the CDC published a universal opt-out recommendation for HIV testing, UK guidelines continued to focus almost completely on STD clinics.⁴ Although, mention of tuberculosis and other conditions suspicious for HIV was made. A recent small sampling of primary and secondary care centers in the UK revealed poor penetrance of HIV testing even for African patients recently immigrated from highly HIV endemic areas.⁵

We have our own significant challenges in achieving goals for HIV screening, and the UK represents a unique health care setting. Also, I am unfamiliar with the intricacies of UK reporting to WHO Europe. However, readers should remain concerned and investigators mindful of the global associations between tuberculosis and HIV patient populations.

WHO Reported Incidence for Tuberculosis and HIV, UK

	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006
Tb	12	12	12	12	12	12	12	13	13	14	---
HIV	5	5	5	5	6	7	10	12	12	14	15
AIDS	3	2	1	1	1	1	1	1	1	1	1

Estimated incidences per 100,000 rounded to whole case. Data abstracted from WHO Europe HFA-DB.

1. Dosanjh DP, Hinks TS, Innes JA, et al. Improved diagnostic evaluation of suspected tuberculosis. Annals of Internal Medicine 2008;148(5):325-36.

2. Menzies D. Using tests for latent tuberculous infection to diagnose active tuberculosis: can we eat our cake and have it too? Annals of Internal Medicine 2008;148(5):398-9.

3. Rose AM, Watson JM, Graham C, et al. Tuberculosis at the end of the 20th century in England and Wales: results of a national survey in 1998. Thorax 2001;56(3):173-9.

4. Rogstad K, Palfreeman A, Rooney G, et al. UK National Guidelines on HIV Testing 2006. International Journal of STD & AIDS 2006;17(10):668-76.

5. Burns FM, Johnson AM, Nazroo J, et al. Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS (London, England) 2008;22(1):115-22.

David M. Brett-Major, M.D.

Division of Infectious Diseases, Department of Internal Medicine, National Naval Medical Center, Bethesda MD; and,

Division of Tropical Public Health, Departments of Preventive Medicine and Biometrics, and Medicine, Uniformed Services University, Bethesda MD

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University, Department of Defense, nor the U.S. Government.

Conflict of Interest:

Conflict of Interest:

Conflict of Interest: