What Works for Women and Girls

There Are Gendered Dynamics in TB Prevalence, DetectionGlobally, more men than women are affected by tuberculosis disease. However, the numbersof women co-infected with TB and HIV are increasing (Adhikari, 2009; Gupta, 2009; Druceand Nolan, 2007; Nissapatorn et al., 2006). In countries with HIV prevalence higher than 1%,relatively equal numbers of men and women are diagnosed with TB.The World Health Organization’s case notification rates indicate that eight times as manymen as women were diagnosed with TB in 2007 (WHO, 2009i). The reasons for the higherglobal TB notification rates in men are not well understood and could result from a varietyof biological or environmental factors such as the likelihood of producing a positive sputumsample, delays in health-seeking behavior, gendered dynamics within the family, stigma andaccess to care: women are less likely to produce positive sputum samples and more likely tohave extrapulmonary TB and/or be co-infected with HIV (Lawson et al., 2008; Karim et al.,2008; Sreeramareddy et al., 2008).Preliminary data suggest that the implementation of the revised WHO case definition ofsmear-positive TB was associated with significant increases in case detection among womenin Kenya (Ramsey et al., 2009). The revised guidance lowers the number of bacilli in a sampleand reduces the number of smear-positive results from two to one required be classified as aTB case. Evidence from a Vietnamese study also suggests that women are slower to progress tosmear-positive disease despite similar time from symptom onset to diagnosis as men (Thorsonet al., 2007). Additionally, some studies have shown that physicians are less likely to conductTB exams on women than men (Begun et al., 2001 cited in Theobald et al., 2006). Furtherresearch is needed on differences in testing and disease manifestation in women and men.Co-Infection is Particularly Deadly for Women During Their Childbearing YearsWomen bear the greatest burden of HIV during their childbearing years, and similarly, thegreatest burden of TB during those years as well. It is estimated that 15% of maternal deathsare among women co-infected with TB and HIV (Adhikari, 2009; Klotz et al., 2007; Mofensonand Laughton, 2007; Zwang et al., 2007; Ramogale et al., 2007; Gupta, 2009). The developmentof TB disease is associated with a four-fold increase in AIDS-related deaths amongwomen co-infected with TB and HIV (Lopez-Gatell et al., 2007). A study in South Africa foundyoung women to be at particular risk. Epidemiologic changes in TB notifications and the prevalenceof HIV infection from 1996 to 2004 in a peri-urban community in South Africa of13,000 found that annual TB notification rates among adolescents increased from zero casesbetween 1996–1997 to 436 cases per 100,000 in 2003–2004, with TB cases predominantlyamong female adolescents (Lawn et al, 2006).The U.S. CDC states that TB treatment for pregnant women should be the same as fornonpregnant women, but with special considerations for particular medications’ effect onboth the woman and the fetus (CDC, 2009a, http://www.aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off&GuidelineID=211&ClassID=4).“Pregnant women on ART who have a diagnosis of active TB should have their ARV regimensadjusted as needed to accommodate their TB drugs. For women whose diagnosis includes270 CHAPTER 10 PREVENTING, DETECTING AND TREATING CRITICAL CO-INFECTIONS