Tuberculosis control in Africa in the face of the HIV epidemic.

The thesis describes some studies and reflections on aspects of tuberculosis control in Africa, specifically in Malawi, in the face of the HIV epidemic. The scourge of the dual infection reaches catastrophic proportions. The impact on economy and mortality is devastating. In the research agenda of the National Tuberculosis Control Programme in collaboration with the College of Medicine of the University of Malawi several topics have been identified for operational research to improve control measures in the fight against TB and AIDS in Africa. Some of these topics and the studies that resulted from it, form the basis of thesis. Several chapters describe studies in the diagnostic process such as a) gender distribution in access to sputum laboratory services, b) a simple strategy in the diagnosis of tuberculous lymphadenitis, c) the role of traditional healers and traditional medicine in TB patients before they are diagnosed in the conventional health institutions and in an other study the care seeking behaviour these patients express, d) the viability of mycobacteria within and outside the refrigerator which is important in remote areas with poor infrastructure and regular power interruptions. Furthermore, there are two chapters that contain studies in the treatment phase: First, a major UNAIDS sponsored project investigates the effect on survival and morbidity of prophylaxis with two different dosages of cotrimoxazole in 579 HIV seropositive TB patients. It suggests that a single dose of 480 mg is as effective as a double dose and that there is a beneficial effect compared to a historical control cohort and the national TB programme outcome parameters. The second study addresses the problem of treatment compliance of TB patients. In a group of about 100 patients registered as defaulters 80% were actually wrongly registered. Lastly, two chapters reflect on possible strategies of TB control in the face of the HIV epidemic in sub-Saharan Africa, and a special emphasis is put on the problems that accompanies the introduction, the delivery and the monitoring of antiretroviral treatment