What Works for Women and Girls

concurrent active TB and HIV infection during pregnancy, TB therapy should be initiatedimmediately and ART should be initiated as soon as possible thereafter, usually according tothe principles described for nonpregnant adults” (CDC, 2009a).Because of the increased risk of maternal and infant mortality associated with TB andHIV co-infection during pregnancy and postpartum, there is an urgent need to implement TBscreening as part of routine antenatal and postpartum care as well as treatment for latent andactive TB for women (Mofenson and Laughton, 2007). Maternal and child health and HIV/AIDS prevention programs that include TB education and screening make these services moreaccessible to women of childbearing age.Active Case Finding Is Necessary to Increase TB DetectionOnly about half of TB suspects seek out TB screening, and it is estimated that about half ofthese cases are misdiagnosed (Ayles, 2009). “Many of the TB control strategies like passivecase finding [as opposed to active case finding where health workers actively screen people forTB symptoms] and directly observed therapy (DOTS), that are used today were developed inthe pre-HIV era, and “[do] not take into account the profound impact of HIV on tuberculosisincidence” (Reid et al., 2006: 485). This situation is compounded by the fact that TB is moredifficult to diagnose in people with HIV-related immune suppression.Active case finding increases TB detection, particularly in sub-Saharan Africa, where HIVis driving the epidemic. For example, instituting an antiretroviral therapy program in a healthcenter in a mountainous region of Lesotho resulted in a 10-fold increase in the detection of TBamong patients with and without HIV (Furin et al., 2007). In the Thyolo district in Malawi,TB/HIV community volunteers screened for TB symptoms and found that households wheresomeone had a chronic cough had an annual TB incidence rate eight times higher than thegeneral population (Zachariah et al., 2006b).However, as noted previously, TB symptoms may be different in people living with HIV,which can complicate diagnosis. A prospective cohort study with 1,768 HIV-positive patientsfrom eight clinics in Cambodia, Vietnam and Thailand found that TB screening that includesquestions about a combination of TB symptoms such as fatigue, fever and weight loss wassignificantly more effective in ruling out TB than asking about cough alone (Cain et al., 2010).HAART Can Reduce the Incidence of TBHighly-active antiretroviral therapy has been shown to reduce the incidence of tuberculosis(Lawn et al., 2005; Wood, 2009). A multi-center cohort study in Spain compared TB incidencein pre-HAART and HAART eras and found that the risk of developing TB was 70% lowerin the HAART era than in the pre-HAART era (Muga et al., 2007). Since the initiation ofHAART, TB incidence among people on HAART in the Gugulethu township in South Africahas decreased significantly while TB incidence has remained stable among HIV-negative andHIV-positive individuals not on HAART (Wood, 2009). Likewise, TB mortality rates amongHIV-positive people have been brought down to comparable levels to HIV-negative individuals(Wood, 2009). A study in Ethiopia that assessed the effect of HAART on patient mortality andWHAT WORKS FOR WOMEN AND GIRLS271