HIV 957
CASE REPORT

Combined antiretroviral and anti-tuberculosis drug resistance following incarceration


K E Stott,1 MB ChB, MSc; T de Oliviera,1,2 BSc (Hons), PhD; R J Lessells,1,3 BSc (MedSci), MB ChB, MRCP, DTM&H, Dip HIV Med

1 Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa

2 Research Department of Infection, University College London, London, United Kingdom

3 Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom

Corresponding author: R J Lessells (rlessells@africacentre.ac.za)


We describe a case of HIV/tuberculosis (TB) co-infection from KwaZulu-Natal, South Africa, characterised by drug resistance in both pathogens. The development of drug resistance was linked temporally to two periods of incarceration. This highlights the urgent need for improved integration of HIV/TB control strategies within prison health systems and within the broader public health framework.

S Afr J HIV Med 2013;14(3):135-137. DOI:10.7196/SAJHIVMED.957


The twin epidemics of HIV and tuberculosis (TB) have had a devastating impact on individuals, families and communities in South Africa (SA) over the past two decades.1 SA alone is responsible for almost one-third of the global burden of HIV-associated TB.2 While much progress has been made in the last few years with robust responses to these epidemics, many challenges remain.3 Antiretroviral and anti-TB drug resistance pose considerable threats to the control of these epidemics.4 , 5 The breakdown in HIV/TB control within prisons is another emerging threat.6 , 7 We describe one of the first reports of combined antiretroviral and anti-TB drug resistance, where the development of resistance was closely associated with two periods of incarceration.

Case report

A 34-year-old unemployed male presented to a primary healthcare (PHC) clinic in Hlabisa sub-district, KwaZulu-Natal, in February 2012 with a cough, night sweats and weight loss. He had been diagnosed with HIV infection in 2002, but had not accessed HIV care until April 2009 when he presented with his first episode of smear-negative pulmonary TB. At that time, his CD4+ cell count was 85 cells/µl and he was initiated on a standard first-line antiretroviral therapy (ART) regimen of stavudine (d4T), lamivudine (3TC), and efavirenz (EFV). He achieved complete virological suppression (HIV viral load <50 copies/ml) and a good immunological response (CD4+ count 482 cells/µl) after 5 months of ART (Fig. 1). In May 2010, he was incarcerated (in a correctional facility approximately 50 km from home) and as a result of non-disclosure of HIV status to prison officials, his ART was interrupted. Following release in September 2010, he had re-engaged with care at the PHC clinic and had been restarted on ART (tenofovir (TDF), 3TC and EFV). Within 6 months, he was once again detained in prison and his ART was interrupted once again for several months. He reported that he shared a cell with up to 50 people during this second spell in prison, several of whom were coughing and one had apparently stated that he had multidrug-resistant TB (MDR-TB).


Fig. 1. Clinical course of ART with results of viral load (VL) and CD4+ cell count monitoring and timing of treatment interruptions.

Xpert® MTB/RIF was performed on sputum and detected Myco­bacterium tuberculosis resistant to rifampicin. He was referred to the provincial drug-resistant TB unit (approximately 250 km from home) and was commenced on a standardised regimen of kanamycin, moxifloxacin, ethionamide, terizidone, pyrazinamide and isoniazid. Two weeks later, he was re-initiated on ART (TDF, 3TC and EFV). He completed the intensive phase of drug-resistant TB treatment with a good treatment response (acid-fast bacilli smear and culture negative after 2 months) and no evidence of nephrotoxicity, but there was no virological response to ART (viral load 390 845 copies/ ml 6 months after restarting ART), despite documented good adherence.

Genotypic resistance testing was performed and revealed non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance mutations (K103N and V106M) and nucleoside reverse transcriptase inhibitor (NRTI) resistance mutations (K65R and M184V), conferring high-level resistance to EFV and 3TC, and intermediate-level resistance to TDF. Hepatitis B surface antigen (HBsAg) was negative and haemoglobin was 12.7 g/dl. As a result, he was switched to a second-line ART regimen consisting of co-formulated zidovudine (AZT) and 3TC with lopinavir/ritonavir (LPV/r). At this stage, the total number of pills taken daily was 27 (including co-trimoxazole and pyridoxine). As of June 2013, he continues to be followed up at his local PHC clinic (2 km from home) and at the drug-resistant TB unit.

Consent

Written informed consent was given by the patient prior to publication.

Discussion

The issue of TB control in SA prisons has recently received much attention, as a result of the successful legal action against the Minister of Correctional Services by a former prison inmate who contracted TB while in a correctional facility awaiting trial.8 Here we have described a case where acquisition of drug-resistant TB most likely occurred in prison and the clinical course was compounded by the emergence of antiretroviral drug resistance. This has significance, not only for individual health, with increased treatment complexity and adverse clinical outcomes, but also for the health of the wider community, with the risk of onward transmission of drug-resistant infections. The case here highlights the need for an improved and more integrated approach to HIV/TB prevention and care in prisons, as well as better linkage between prison health services and the public health system.

The incidence of TB disease in prisons worldwide has been shown to be more than 20 times that of the general population.9 This is widely attributed to factors such as overcrowding, poor nutrition, insufficient ventilation and inadequate health services in prisons.7 , 10-12 The problem is amplified in countries with a high HIV burden, as HIV infection is the strongest individual risk factor for developing active TB.12-14 HIV prevalence is also often higher than that among the general population, with estimates of 40 - 45% in SA prisons.15 , 16 Only 40% of SA correctional centres report segregating inmates on medical grounds, although drug-resistant TB has been cited as the most common reason for such segregation.17 Ventilation is frequently poor;6 , 11 our patient described small, slit-like windows high up on one exterior wall of his cell. There is a shortage of medical personnel in prisons and delays in accessing care are frequently an issue;6 , 8 , 11 , 17 our patient stated that, during his second period of detention, he had reported his cough and night sweats to prison officials for 3 weeks before he was taken to the prison health facility.

The epidemiology of communicable diseases within and outside prisons is closely related; large numbers of prisoners and staff enter and leave prisons on a daily basis, acting as potential sources of transmission to the community at large. In SA in 2011/ 2012, over 80% of remand detainees17 and 40% of those who received sentences were imprisoned for less than one year.18 Thus, in SA, as elsewhere, prisons act as reservoirs of TB, and inevitably drug-resistant TB, that poses a threat to public health control.12 , 14 Despite this, control measures for TB, HIV and other communicable diseases are often neglected, relative to measures directed at non-prison populations.19

Many of the same factors that enhance the spread of TB in prisons encourage the emergence of drug resistance and subsequent transmission of drug-resistant TB.10 , 19 Moreover, the failure to ensure prompt recognition and appropriate treatment of drug-resistant cases results in a prolonged infective period, such that transmission risks may be even higher than those associated with drug-susceptible TB.11 There are additional factors that may particularly promote the development of drug-resistant TB in prisons, such as: erratic drug supply and inadequate treatment; access to uncontrolled anti-TB drugs from staff and visitors; and chaotic lifestyles, including transfers between and within prisons. These enhance the likelihood of treatment interruption or default.19

While there is a paucity of data on antiretroviral drug resistance in prison populations, HIV-positive prisoners receiving ART in Brazil have been found to have high rates of acquired HIV drug resistance;20 and release from prison followed by re-incarceration has been shown to be associated with impaired virological and immunological outcomes while receiving ART.21 Unplanned treatment interruptions are known to promote resistance;22-24 and chaotic lifestyles,18 , 19 fear of stigmatisation18 , 25 and poor health services in prisons6 , 25 are likely to increase the frequency of treatment interruptions. In SA, most prisons do not have dedicated HIV care programmes and those that exist are delivered by external service providers.17 Our patient did not disclose his HIV-positive status or use of ART during either spell in prison, primarily due to fear of stigmatisation. While the timing of the development of ART drug resistance cannot be ascertained definitively in this case, it is plausible that the unscheduled interruption of treatment during the first period of incarceration could have led to the initial emergence of resistance. Certainly the interruption of ART, the emergence of ART drug resistance and the resultant drop in CD4+ cell count would have substantially increased the risk of developing TB disease.26 We cannot definitively reject the possibility that ART resistance emerged prior to incarceration or that super-infection with a drug-resistant HIV strain occurred during incarceration.

The interdependence of numerous transmission risk factors necessitates a multifaceted approach to TB control in prisons, involving improvement in case finding, reductions in overcrowding and improvements in environmental conditions such as ventilation and airflow.6 , 10-12 , 14 Robust evidence for action already exists: a modelling analysis based on conditions for inmates awaiting trial in Pollsmoor prison, Cape Town, suggested a potential reduction in TB transmission rates of 50% if active case finding and national minimum standards of cell occupancy were implemented; and a reduction of 94% if international environmental standards were adopted.11 Screening and case detection in prisons worldwide has, until recently, been limited by suboptimal diagnostic tools and a lack of adequate laboratory facilities. 27 There is some evidence to suggest that screening prisoners using Xpert MTB/RIF could be a cost-effective means to reduce transmission of drug-resistant TB in settings with a high burden of drug resistance.28 The recent announcement that correctional facilities in SA will now be prioritised for deployment of Xpert MTB/RIF offers strong encouragement.29 However, research is needed to inform policies on the optimal use of Xpert MTB/RIF within prison health services, and any strategy must be linked to appropriate treatment programmes and proper segregation processes.

Furthermore, this case highlights that reducing the individual risk of TB disease should be as important, and optimising individual management of HIV disease, with the aim of virological suppression and prevention of antiretroviral resistance, should be a critical component of broader prison HIV/TB control strategies. No single intervention will adequately address the complex issues relating to TB and HIV in prisons. Ultimately, there needs to be the political will and funding to deliver sustained improvements to prison conditions and health services. Collaboration between the Department of Correctional Services and the Department of Health is necessary to facilitate better integration of prison health services within the public health system. The high costs of managing drug-resistant TB and HIV disease should be a powerful incentive to implement measures to reduce the emergence and spread of drug-resistant TB and HIV.30-32 At a time when considerable progress is being made in the public health sector in SA,3 the failure to address TB and HIV in prisons has the potential to seriously undermine the control of these infectious diseases in the community.

Acknowledgement. This work was supported by the Wellcome Trust (grant 090999/Z/09/Z), European Union (SANTE 2007 147–790), the United States Centres for Diseases Control via the Centre for the AIDS Programme of Research in South Africa (CAPRISA) (project title: Health Systems Strengthening and HIV Treatment Failure (HIV-TFC)) and the Swiss South African Joint Research Programme (SSJRP) research grant entitled ‘Swiss Prot/South Africa: Protein Bioinformatics Resource Development for Important Health-related Pathogens’. The funders had no role in data collection and analysis, decision to publish or preparation of the manuscript.

Author contributions. KES and RJL looked after the patient. KES wrote the first draft of the manuscript. All authors contributed to revision of the manuscript and approved the final version.

References
    1. Abdool Karim SS, Churchyard GJ, Abdool Karim Q, Lawn SD. HIV infection and tuberculosis in South Africa: An urgent need to escalate the public health response. Lancet 2009;374(9693):921-933. [http://dx.doi.org/10.1016/S0140-6736(09)60916-8]

    1. Abdool Karim SS, Churchyard GJ, Abdool Karim Q, Lawn SD. HIV infection and tuberculosis in South Africa: An urgent need to escalate the public health response. Lancet 2009;374(9693):921-933. [http://dx.doi.org/10.1016/S0140-6736(09)60916-8]

    2. Getahun H, Gunneberg C, Granich R, Nunn P. HIV infection-associated tuberculosis: The epidemiology and the response. Clin Infect Dis 2010;50(suppl 3):S201-S207. [http://dx.doi.org/10.1086/651492]

    2. Getahun H, Gunneberg C, Granich R, Nunn P. HIV infection-associated tuberculosis: The epidemiology and the response. Clin Infect Dis 2010;50(suppl 3):S201-S207. [http://dx.doi.org/10.1086/651492]

    3. Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Abdool Karim SS, Coovadia HM. Health in South Africa: Changes and challenges since 2009. Lancet 2012;380(9858):2029-2043. [http://dx.doi.org/10.1016/S0140-6736(12)61814-5]

    3. Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Abdool Karim SS, Coovadia HM. Health in South Africa: Changes and challenges since 2009. Lancet 2012;380(9858):2029-2043. [http://dx.doi.org/10.1016/S0140-6736(12)61814-5]

    4. Gandhi NR, Nunn P, Dheda K, et al. Multidrug-resistant and extensively drug-resistant tuberculosis: A threat to global control of tuberculosis. Lancet 2010;375(9728):1830-1843. [http://dx.doi.org/10.1016/S0140-6736(10)60410-2]

    4. Gandhi NR, Nunn P, Dheda K, et al. Multidrug-resistant and extensively drug-resistant tuberculosis: A threat to global control of tuberculosis. Lancet 2010;375(9728):1830-1843. [http://dx.doi.org/10.1016/S0140-6736(10)60410-2]

    5. Hamers RL, Kityo C, Lange JM, De Wit R, Mugyenyi P. Global threat from drug resistant HIV in sub-Saharan Africa. BMJ 2012;344:e4159. [http://dx.doi.org/10.1136/bmj.e4159]

    5. Hamers RL, Kityo C, Lange JM, De Wit R, Mugyenyi P. Global threat from drug resistant HIV in sub-Saharan Africa. BMJ 2012;344:e4159. [http://dx.doi.org/10.1136/bmj.e4159]

    6. Reid SE, Topp SM, Turnbull ER, et al. Tuberculosis and HIV control in sub-Saharan African prisons: “Thinking outside the prison cell”. J Infect Dis 2012;205(suppl 2):S265-S273. [http://dx.doi.org/10.1093/infdis/jis029]

    6. Reid SE, Topp SM, Turnbull ER, et al. Tuberculosis and HIV control in sub-Saharan African prisons: “Thinking outside the prison cell”. J Infect Dis 2012;205(suppl 2):S265-S273. [http://dx.doi.org/10.1093/infdis/jis029]

    7. Todrys KW, Amon JJ. Criminal justice reform as HIV and TB prevention in African prisons. PLoS Med 2012;9(5):e1001215. [http://dx.doi.org/10.1371/journal.pmed.1001215]

    7. Todrys KW, Amon JJ. Criminal justice reform as HIV and TB prevention in African prisons. PLoS Med 2012;9(5):e1001215. [http://dx.doi.org/10.1371/journal.pmed.1001215]

    8. South African Legal Information Institute. Lee v Minister of Correctional Services (10416/04). Johannesburg: South African Legal Information Institute, 2011. http://www.saflii.org/za/cases/ZAWCHC/2011/13.html (accessed 18 June 2013).

    8. South African Legal Information Institute. Lee v Minister of Correctional Services (10416/04). Johannesburg: South African Legal Information Institute, 2011. http://www.saflii.org/za/cases/ZAWCHC/2011/13.html (accessed 18 June 2013).

    9. Baussano I, Williams BG, Nunn P, Beggiato M, Fedeli U, Scano F. Tuberculosis incidence in prisons: A systematic review. PLoS Med 2010;7(12):e1000381. [http://dx.doi.org/10.1371/journal.pmed.1000381]

    9. Baussano I, Williams BG, Nunn P, Beggiato M, Fedeli U, Scano F. Tuberculosis incidence in prisons: A systematic review. PLoS Med 2010;7(12):e1000381. [http://dx.doi.org/10.1371/journal.pmed.1000381]

    10. O’Grady J, Mwaba P, Bates M, Kapata N, Zumla A. Tuberculosis in prisons in sub-Saharan Africa: A potential time bomb. S Afr Med J 2011;101(2):107-108.

    10. O’Grady J, Mwaba P, Bates M, Kapata N, Zumla A. Tuberculosis in prisons in sub-Saharan Africa: A potential time bomb. S Afr Med J 2011;101(2):107-108.

    11. Johnstone-Robertson S, Lawn SD, Welte A, Bekker LG, Wood R. Tuberculosis in a South African prison: A transmission modelling analysis. S Afr Med J 2011;101(11):809-813.

    11. Johnstone-Robertson S, Lawn SD, Welte A, Bekker LG, Wood R. Tuberculosis in a South African prison: A transmission modelling analysis. S Afr Med J 2011;101(11):809-813.

    12. O’Grady J, Hoelscher M, Atun R, et al. Tuberculosis in prisons in sub-Saharan Africa – the need for improved health services, surveillance and control. Tuberculosis 2011;91(2):173-178. [http://dx.doi.org/10.1016/j.tube.2010.12.002]

    12. O’Grady J, Hoelscher M, Atun R, et al. Tuberculosis in prisons in sub-Saharan Africa – the need for improved health services, surveillance and control. Tuberculosis 2011;91(2):173-178. [http://dx.doi.org/10.1016/j.tube.2010.12.002]

    13. Ferrari M. Eleven million adults co-infected with AIDS, TB. CMAJ 2004;171(5):437. [http://dx.doi.org/10.1503/cmaj.1041249]

    13. Ferrari M. Eleven million adults co-infected with AIDS, TB. CMAJ 2004;171(5):437. [http://dx.doi.org/10.1503/cmaj.1041249]

    14. Maher D, Grzemska M, Coninx R, Reyes H. Guidelines for the control of tuberculosis in prisons. Geneva: World Health Organization, 1998. http://whqlibdoc.who.int/hq/1998/WHO_TB_98.250.pdf (accessed 18 June 2013).

    14. Maher D, Grzemska M, Coninx R, Reyes H. Guidelines for the control of tuberculosis in prisons. Geneva: World Health Organization, 1998. http://whqlibdoc.who.int/hq/1998/WHO_TB_98.250.pdf (accessed 18 June 2013).

    15. Dolan K, Kite B, Black E, Aceijas C, Stimson GV. HIV in prison in low-income and middle-income countries. Lancet Infect Dis 2007;7(1):32-41. [http://dx.doi.org/10.1016/S1473-3099(06)70685-5]

    15. Dolan K, Kite B, Black E, Aceijas C, Stimson GV. HIV in prison in low-income and middle-income countries. Lancet Infect Dis 2007;7(1):32-41. [http://dx.doi.org/10.1016/S1473-3099(06)70685-5]

    16. World Health Organization, United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS. Effectiveness of interventions to address HIV in prisons. Evidence for Action Technical Paper. Geneva: WHO, 2007. http://whqlibdoc.who.int/publications/2007/9789241596190_eng.pdf (accessed 18 June 2013).

    16. World Health Organization, United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS. Effectiveness of interventions to address HIV in prisons. Evidence for Action Technical Paper. Geneva: WHO, 2007. http://whqlibdoc.who.int/publications/2007/9789241596190_eng.pdf (accessed 18 June 2013).

    17. Judicial Inspectorate for Correctional Services. Annual report for the period 1 April 2011 to 31 March 2012. Durban: Judicial Inspectorate for Correctional Services, 2012. http://judicialinsp.dcs.gov.za/Annualreports/Annual%20Report%202011-2012.pdf (accessed 18 June 2013).

    17. Judicial Inspectorate for Correctional Services. Annual report for the period 1 April 2011 to 31 March 2012. Durban: Judicial Inspectorate for Correctional Services, 2012. http://judicialinsp.dcs.gov.za/Annualreports/Annual%20Report%202011-2012.pdf (accessed 18 June 2013).

    18. Goyer K. HIV/AIDS in prison: Problems, policies and potential. Institute for Security Studies Monographs 2003;2(79).

    18. Goyer K. HIV/AIDS in prison: Problems, policies and potential. Institute for Security Studies Monographs 2003;2(79).

    19. World Health Organization. TB control in prisons: A manual for programme managers. Geneva: WHO, 2000. http://whqlibdoc.who.int/hq/2000/WHO_CDS_TB_2000.281.pdf (accessed 18 June 2013).

    19. World Health Organization. TB control in prisons: A manual for programme managers. Geneva: WHO, 2000. http://whqlibdoc.who.int/hq/2000/WHO_CDS_TB_2000.281.pdf (accessed 18 June 2013).

    20. Cardoso LPV, da Silveira AA, Francisco RBL, da Guarda Reis MN, de Araújo Stefani MM. Molecular characteristics of HIV type 1 infection among prisoners from central western Brazil. AIDS Res Hum Retroviruses 2011;27(12):1349-1353. [http://dx.doi.org/10.1089/aid.2011.0153]

    20. Cardoso LPV, da Silveira AA, Francisco RBL, da Guarda Reis MN, de Araújo Stefani MM. Molecular characteristics of HIV type 1 infection among prisoners from central western Brazil. AIDS Res Hum Retroviruses 2011;27(12):1349-1353. [http://dx.doi.org/10.1089/aid.2011.0153]

    21. Stephenson BL, Wohl DA, Golin E, Tien HC, Stewart P, Kaplan AH. Effect of release from prison and re-incarceration on the viral loads of HIV-infected individuals. Public Health Rep 2005;120(1):84-88.

    21. Stephenson BL, Wohl DA, Golin E, Tien HC, Stewart P, Kaplan AH. Effect of release from prison and re-incarceration on the viral loads of HIV-infected individuals. Public Health Rep 2005;120(1):84-88.

    22. Oyugi JH, Byakika-Tusiime J, Ragland K, et al. Treatment interruptions predict resistance in HIV-positive individuals purchasing fixed-dose combination antiretroviral therapy in Kampala, Uganda. AIDS 2007;21(8):965-971. [http://dx.doi.org/10.1097/QAD.0b013e32802e6bfa]

    22. Oyugi JH, Byakika-Tusiime J, Ragland K, et al. Treatment interruptions predict resistance in HIV-positive individuals purchasing fixed-dose combination antiretroviral therapy in Kampala, Uganda. AIDS 2007;21(8):965-971. [http://dx.doi.org/10.1097/QAD.0b013e32802e6bfa]

    23. Delaugerre C, Valantin MA, Mouroux M, et al. Re-occurrence of HIV-1 drug mutations after treatment re-initiation following interruption in patients with multiple treatment failure. AIDS 2001;15(16):2189-2191. [http://dx.doi.org/10.1097/00002030-200111090-00016]

    23. Delaugerre C, Valantin MA, Mouroux M, et al. Re-occurrence of HIV-1 drug mutations after treatment re-initiation following interruption in patients with multiple treatment failure. AIDS 2001;15(16):2189-2191. [http://dx.doi.org/10.1097/00002030-200111090-00016]

    24. Harrigan PR, Hogg RS, Dong WWY, et al. Predictors of HIV drug-resistance mutations in a large antiretroviral-naive cohort initiating triple antiretroviral therapy. J Infect Dis 2005;191(3):339-347. [http://dx.doi.org/10.1086/427192]

    24. Harrigan PR, Hogg RS, Dong WWY, et al. Predictors of HIV drug-resistance mutations in a large antiretroviral-naive cohort initiating triple antiretroviral therapy. J Infect Dis 2005;191(3):339-347. [http://dx.doi.org/10.1086/427192]

    25. United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS, World Bank. HIV and prisons in sub-Saharan Africa: Opportunities for action. Vienna: United Nations Office on Drugs and Crime, 2007. http://www.unodc.org/documents/hiv-aids/Africa%20HIV_Prison_Paper_Oct-23-07-en.pdf (accessed 18 June 2013).

    25. United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS, World Bank. HIV and prisons in sub-Saharan Africa: Opportunities for action. Vienna: United Nations Office on Drugs and Crime, 2007. http://www.unodc.org/documents/hiv-aids/Africa%20HIV_Prison_Paper_Oct-23-07-en.pdf (accessed 18 June 2013).

    26. Lawn SD, Myer L, Edwards D, Bekker LG, Wood R. Short-term and long-term risk of tuberculosis associated with CD4 cell recovery during antiretroviral therapy in South Africa. AIDS 2009;23(13):1717-1725. [http://dx.doi.org/10.1097/QAD.0b013e32832d3b6d]

    26. Lawn SD, Myer L, Edwards D, Bekker LG, Wood R. Short-term and long-term risk of tuberculosis associated with CD4 cell recovery during antiretroviral therapy in South Africa. AIDS 2009;23(13):1717-1725. [http://dx.doi.org/10.1097/QAD.0b013e32832d3b6d]

    27. Vinkeles Melchers NVS, van Elsland SL, Lange JMA, Borgdorff MW, van den Hombergh J. State of affairs of tuberculosis in prison facilities: A systematic review of screening practices and recommendations for best TB control. PLoS ONE 2013;8(1):e53644. [http://dx.doi.org/10.1371/journal.pone.0053644]

    27. Vinkeles Melchers NVS, van Elsland SL, Lange JMA, Borgdorff MW, van den Hombergh J. State of affairs of tuberculosis in prison facilities: A systematic review of screening practices and recommendations for best TB control. PLoS ONE 2013;8(1):e53644. [http://dx.doi.org/10.1371/journal.pone.0053644]

    28. Winetsky DE, Negoescu DM, DeMarchis EH, et al. Screening and rapid molecular diagnosis of tuberculosis in prisons in Russia and Eastern Europe: A cost-effectiveness analysis. PLoS Med 2012;9(11):e1001348. [http://dx.doi.org/10.1371/journal.pmed.1001348]

    28. Winetsky DE, Negoescu DM, DeMarchis EH, et al. Screening and rapid molecular diagnosis of tuberculosis in prisons in Russia and Eastern Europe: A cost-effectiveness analysis. PLoS Med 2012;9(11):e1001348. [http://dx.doi.org/10.1371/journal.pmed.1001348]

    29. Republic of South Africa. Address by Deputy President of South Africa Kgalema Motlanthe at the World TB Day, Pollsmoor Management Centre, Cape Town, 2013. http://www.thepresidency.gov.za/pebble.asp?relid=15108 (accessed 18 June 2013).

    29. Republic of South Africa. Address by Deputy President of South Africa Kgalema Motlanthe at the World TB Day, Pollsmoor Management Centre, Cape Town, 2013. http://www.thepresidency.gov.za/pebble.asp?relid=15108 (accessed 18 June 2013).

    30. Pooran A, Pieterson E, Davids M, Theron G, Dheda K. What is the cost of diagnosis and management of drug resistant tuberculosis in South Africa? PLoS ONE 2013;8(1):e54587. [http://dx.doi.org/10.1371/journal.pone.0054587]

    30. Pooran A, Pieterson E, Davids M, Theron G, Dheda K. What is the cost of diagnosis and management of drug resistant tuberculosis in South Africa? PLoS ONE 2013;8(1):e54587. [http://dx.doi.org/10.1371/journal.pone.0054587]

    31. Schnippel K, Rosen S, Shearer K, et al. Costs of inpatient treatment for multi-drug-resistant tuberculosis in South Africa. Trop Med Int Health 2013;18(1):109-116. [http://dx.doi.org/10.1111/tmi.12018].

    31. Schnippel K, Rosen S, Shearer K, et al. Costs of inpatient treatment for multi-drug-resistant tuberculosis in South Africa. Trop Med Int Health 2013;18(1):109-116. [http://dx.doi.org/10.1111/tmi.12018].

    32. Long L, Fox M, Sanne I, Rosen S. The high cost of second-line antiretroviral therapy for HIV/AIDS in South Africa. AIDS 2010;24(6):915-919. [http://dx.doi.org/10.1097/QAD.0b013e3283360976]

    32. Long L, Fox M, Sanne I, Rosen S. The high cost of second-line antiretroviral therapy for HIV/AIDS in South Africa. AIDS 2010;24(6):915-919. [http://dx.doi.org/10.1097/QAD.0b013e3283360976]


 

Crossref Citations

1. Do Incarcerated Populations Serve as a Reservoir for Tuberculosis in South Africa?
Alana Sharp, J. Travis Donahoe, Amanda Milliken, Jacqueline Barocio, Salome Charalambous, Zoë M. McLaren
The American Journal of Tropical Medicine and Hygiene  vol: 99  issue: 6  first page: 1390  year: 2018  
doi: 10.4269/ajtmh.17-0652