Directly Observed Treatment Short Course Strategy Research Articles

Involvement of pharmacies in tuberculosis treatment

To the Editors: In a recent issue of the European Respiratory Journal , Yew et al . [1] recalled the change from DOTS (directly observed treatment, short course) strategy to a more comprehensive approach, the Stop TB Strategy, adopted by the World Health Organization. Three of the six components of this strategy are the pursuit of high-quality DOTS expansion and enhancement, the engagement of all care providers, and the empowerment of people with tuberculosis and communities through partnership. We present a project based on the decentralisation of treatment and on patient participation in the choice of DOT supporter, in line with the Stop TB Strategy as presented by Yew et al. [1]. In Portugal, DOT is mandatory, and is performed principally in an outpatient setting within Pulmonary Health Centers (CDPs); these are primary care units dedicated to the diagnosis, treatment and surveillance of tuberculosis. Tuberculosis patients continue to suffer from social stigma and find it embarrassing to be subjected to DOT in CDP facilities. To deal with this problem, the Vila Nova de Gaia CDP team and the National Association of Pharmacies (ANF) designed and implemented a …

Compliance with DOTS among tuberculosis patients under community based DOTS strategy in Palpa District, Nepal

INTRODUCTION: Palpa is one of the rural districts of Nepal with high incidence of tuberculosis (TB) where Community Based Directly Observed Treatment Short Course (DOTS) strategy was being trailed to make TB services accessible at community level. In spite of this, it has high defaulter rate; every year more than 5% patients had defaulted from the treatment and death due to TB was around 6%. The study, therefore, aimed to assess the patients’ compliance to the treatment and its associated factors. MATERIALS AND METHODS: A quantitative crosssectional study was carried out using structured interview schedule. All registered TB patients (n=101) who were on treatment were enrolled in the study. RESULTS: TB patients of younger age group were found to be more compliant to the treatment (p=0.02). Side effect of the drugs was the major reason for the non compliance (36.00%). More than half of the TB patients had poor knowledge on TB and its treatment. Compliance was found to be significantly associated with knowledge (p=0.02) and perception (p=0.02) of the patients towards TB. Similarly, the study showed positive association between the compliance and service accessibility (distance: p=0.00), availability of treatment supervisor (p=0.01) and health education (p=0.02). CONCLUSIONS: Patients’ compliance with the TB treatment was found to be associated with their knowledge and perception on TB and its treatment. Health education and proper counseling was deemed necessary for the patients. Service accessibility along with communication skills training to the providers including community health volunteers can increase compliance rate. DOI: http://dx.doi.org/10.3126/ijim.v1i1.6717Int J Infect Microbiol 2012;1(1):14-19

Efficacy of directly observed treatment short-course intermittent regimen in spinal tuberculosis

Background:Most important cause of treatment failure and emergence of drug resistance in the treatment of tuberculosis is noncompliance. Compliance can be improved by direct observation of drug intake, intermittent therapy, and short-course treatment. The efficacy of Directly Observed Treatment Short Course (DOTS) strategy advocated by World Health Organization (WHO) in spinal tuberculosis is not yet proven. We conducted a prospective clinical study on a consecutive series of patients with spinal tuberculosis treated by Category I Revised National Tuberculosis Control Programme (RNTCP) regimen based on DOTS strategy of WHO from 2004 to 2007 to evaluate the efficacy.Materials and Methods:Forty-nine consecutive patients of spinal tuberculosis were treated with short-course intermittent chemotherapy under Category I RNTCP/DOTS strategy. Patients were followed up for a minimum period of 2 years. Surgery was done if the patient presented with significant neurologic deficit or when the drug treatment failed. Outcome was assessed by clinical, radiologic, and laboratory criteria, and graded into excellent, good, fair, and poor based on various parameters.Results:63.4% (n=26) of the patients had excellent results. 14.6% (n=6) of the patients had good and fair results. Three patients (7.3%) had poor results 48.7% (n=20) of the patients had but only one of them was severe enough to warrant change of drug.Conclusions:Efficacy of DOTS was comparable with other standard regimens. There was a significant reduction in adverse side effects when compared with daily regimens. Study showed that the outcome was better in those treated early.

Anti-Tuberculosis Drugs and Human Polymorphonuclear Leukocyte Functions

Background: The polymorphonuclear leukocyte (PMN) is considered to be of importance in the early stages of human tuberculosis (TB). We examined the four drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) commonly used in the DOTS (directly observed treatment, short-course) strategy against TB for their effects on the functions of the human PMN, separately and combined. Methods: PMNs were incubated with subtherapeutic, therapeutic and supratherapeutic concentrations of the drugs before being tested for phagocytosis and oxidative burst capacity with Staphylococcus aureus opsonized with pooled human serum as stimuli. Flow cytometric techniques were used to compare PMN phagocytosis and oxidative burst with and without incubation in different concentrations of the drugs. Results: None of the drugs influenced PMN phagocytosis as measured by flow cytometry. Oxidative burst was attenuated only with the highest (and supratherapeutic) concentrations of isoniazid and of the combined drugs as compared to lower concentrations. Conclusions: This suggests that any deterioration in PMN function observed in TB is probably associated with the disease per se and not with the anti-TB treatment.

Bridging implementation, knowledge, and ambition gaps to eliminate tuberculosis in the United States and globally.

We reflect on remarkable accomplishments in global tuberculosis (TB) control and identify persistent obstacles to the successful elimination of TB from the United States and globally. One hundred and twenty nine years after Koch’s discovery of the etiologic agent of TB, this health scourge continues to account for 9.4 million cases and 1.7 million deaths annually worldwide. Implementation of the Directly Observed Treatment Short-course strategy from 1995 through 2009 has saved 6 million lives. TB control is increasingly being achieved in countries with high-income economies, yet TB continues to plague persons living in countries with low-income and lower-middle–income economies. To accelerate progress against the global effects of disease caused by TB and achieve its elimination, we must bridge 3 key gaps in implementation, knowledge, and ambition.

Implementing Tuberculosis Control in Papua New Guinea: A Clash of Culture and Science?

Tuberculosis (TB) remains a major health problem in Papua New Guinea (PNG) and the Directly Observed Treatment Short course (DOTS) strategy has been adopted as a framework for controlling the disease. We review here the local and cultural factors in PNG that act as barriers to implementing each component of the DOTS program. Political Will is needed to tackle the underlying conditions that lead to squatter settlements, e.g. poverty and unemployment, and to build infrastructure for access to rural populations. Better case detection may be obtained by addressing the cultural beliefs that delay presentation to health facilities, as well as providing ongoing training for laboratory technicians, introducing better sputum microscopy techniques and regular service of radiology equipment. Direct observation of therapy may need to be done using the traditional clan structure, e.g. clan chiefs and extended family system in rural areas. Effective drug supply is provided by the World Health Organisation (WHO) Global Drug Facility (GDF). Monitoring and Evaluation will require innovative approaches; perhaps through financial incentives on completion of the program or texting through the mobile text messaging for reminders. There are unique cultural and local issues that need to be addressed when implementing DOTS strategy in PNG.

Missed opportunity for standardized diagnosis and treatment among adult Tuberculosis patients in hospitals involved in Public-Private Mix for Directly Observed Treatment Short-Course strategy in Indonesia: a cross-sectional study

BackgroundThe engagement of hospitals in Public-Private Mix (PPM) for Directly Observed Treatment Short-Course (DOTS) strategy has increased rapidly internationally - including in Indonesia. In view of the rapid global scaling-up of hospital engagement, we aimed to estimate the proportion of outpatient adult Tuberculosis patients who received standardized diagnosis and treatment at outpatients units of hospitals involved in the PPM-DOTS strategy.MethodsA cross-sectional study using morbidity reports for outpatients, laboratory registers and Tuberculosis patient registers from 1 January 2005 to 31 December 2005. By quota sampling, 62 hospitals were selected. Post-stratification analysis was conducted to estimate the proportion of Tuberculosis cases receiving standardized management according to the DOTS strategy.ResultNineteen to 53% of Tuberculosis cases and 4-18% of sputum smear positive Tuberculosis cases in hospitals that participated in the PPM-DOTS strategy were not treated with standardized diagnosis and treatment as in DOTS.ConclusionThis study found that a substantial proportion of TB patients cared for at PPM-DOTS hospitals are not managed under the DOTS strategy. This represents a missed opportunity for standardized diagnoses and treatment. A combination of strong individual commitment of health professionals, organizational supports, leadership, and relevant policy in hospital and National Tuberculosis Programme may be required to strengthen DOTS implementation in hospitals.

Public Health Care Practitioner’s Reflections on Tuberculosis Patient’s Perspectives on Factors Influencing their Adherence to the Directly

The high prevalence of tuberculosis (TB) in South Africa is well established. TB, Human Immunodeficiency Virus (HIV), and Auto Immune Deficiency Syndrome (AIDS) co-exist, which contributes to the high incidence, prevalence, and recurrent infection rate of TB. Despite the implementation of the Directly Observed Treatment Short Course (DOTS) strategy, a World Health Organisation (WHO) initiative to stop the spread of the disease by 2015, TB continues to threaten the health of many, especially those in under-resourced, communities. TB patients' adherence to the treatment programme (DOTS) is vital to the reduction of the re-infection rate and the prevention of new cases. Health care practitioner's commitment and professional engagement within a patient-centred health care model is essential to the success of the DOTS initiative. th highest TB rate in the world, with a low treatment success rate (1). It is reported that South Africa's cure rate for TB is 57% despite the implementation of the DOTS strategy (2). Consequently, the effectiveness of this strategy has been called into question. Further, the fact that 70% of the budget of the TB Control Programme in SA is going into multi-drug resistant (MDR) and extensively-drug resistant (XDR), TB has been highlighted (2). TB and HIV co-infection are added to the disease burden. TB speeds up the progress of HIV and AIDS and vice versa. The percentage of smear positive cases for TB and HIV co- infection in SA was 24.9% in 2005. Given the epidemio- logical context of TB and TB/HIV/AIDS co-infection, adherence to anti-TB treatment methods, such as the DOTS strategy, is critical. Treatment success is of course also influenced by external factors of the infected individual, such as the overall quality of the health care provided. The aim of this study was to explore, through the use of a focus group, TB health care practitioner's responses to TB patient's understanding of the factors that promote and the factors that serve as barriers to their adherence to the DOTS programme. It was expected that ascertaining health care practitioner's perspectives will assist in improving health care by modifying existing programmes and introducing new and innovative ones. Understanding health care practitioner's perspectives is critical in promoting the anti-TB drive worldwide, primarily because it is well established that the quality of the communication between the patients and the health service practitioner may pose a barrier to adherence (or may indeed improve it) (3). Moreover, there is an evi-

Reversing the tuberculosis upwards trend: a success story in Romania

At present, no published evidence is available on the effectiveness of the DOTS (directly observed treatment, short-course) strategy in reducing the incidence of tuberculosis (TB) within a country in the European "hot spots". The present study aimed to demonstrate the effectiveness of the strategy implementation in reversing the epidemiological TB trend in Romania based on programmatic data analysis. Key programme indicators were analysed from 1998 to 2007, and included DOTS coverage, case-detection rate, treatment success and overall incidence of notified cases. Internationally agreed definitions were used. The key programme indicators began declining and the World Health Assembly targets were reached (79% case-detection of new sputum-smear positive cases and 85.5% success rate in new culture-positive TB cases), 7 yrs after initiation of the DOTS expansion. The success story in Romania suggests that other middle-income, high-incidence countries (i.e. those belonging to the former Soviet Union) might be able to reach the World Health Assembly Targets and curb the burden of tuberculosis.

Achieving quality in the Directly Observed Treatment Short-course (DOTS) strategy implementation process: a challenge for hospital Public–Private Mix in Indonesia

Background: The Directly Observed Treatment Short-course (DOTS) expansion strategy through Public–Private Mix (PPM) is in progress at an international level as well as in Indonesia. The number of hospitals involved in PPM has been rapidly scaling up, requiring the assessment of quality of implementation.Objective: The paper presents the assessment of quality in implementing DOTS strategy in hospitals in Indonesia and emphasises the challenge of achieving high process quality in managing adult TB cases seen in the outpatient unit.Design: A multiple-case study, involving eight general hospitals in Yogyakarta and Central Java provinces. The cases are comprised of public and private hospitals as well as teaching and non-teaching hospitals. Using the Donabedian's model, the quality of DOTS strategy implementation in hospitals was assessed in three aspects, i.e. structure, process and outcome. Data were collected through self-administered questionnaires, focus group discussions, interviews, observation and documents.Results: The study revealed the importance of process, i.e. mainly commitment and case holding process, to the treatment success rate, treatment completion rate and default rate.Conclusion: A systemic approach and structural support from the hospital is critical in this endeavour. Process improvement in the implementation of DOTS strategy in hospitals should be given more emphasis in hospital PPM-DOTS.

Nursing knowledge production in tuberculosis control in Brazil

Brazilian nursing has been developing research related to the production of essential and priority knowledge for public health, particularly tuberculosis (TB), considering that Brazil is one of the countries responsible for 80% of TB cases in the world. The Millennium Development Goals set targets for the control of neglected diseases. New strategies have been developed to achieve them. Brazilian nursing follows the guidelines of the Global Plan to STOP TB in research and care, in which Human Resources emerge as one of the main challenges to expand the DOTS (Directly Observed Treatment Short-Course) strategy. Scientific nursing production in TB has expanded its scope of analysis in the last decade (1998-2008), incorporating new actors and innovations in the health care process, such as DOTS. The theoretical reference framework is based on vulnerability, humanization and adherence/abandonment concepts. Innovations in the management of the TB health care process are also addressed, inserted in the primary health care system. Another Nursing tendency is the coordination of collaborative research projects in tuberculosis, the Brazilian Tuberculosis Research Network – (REDE TB) and the Latin-American TB Nursing Network. Research production on TB teaching in undergraduate nursing courses in Brazil is highlighted. Scientific nursing production in TB has contributed to generate new knowledge on social and political determinants, especially in understanding aspects related to the patient, the family and health services. The nursing area in TB has worked towards the construction of research competencies integrated with health practices in different scenarios, permitting advances in researchers’ qualification and knowledge production that contributes to TB care in Brazil.

Capacity of healthcare facilities in the implementation of Direct Observed Treatment strategy for tuberculosis in Arumeru and Karatu districts, Tanzania

Directly Observed Treatment Short course strategy (DOTS) has proved to have potential improvement in tuberculosis (TB) control in Tanzania. The objective of this cross sectional study was to assess the capacity of health facilities in implementing DOTS, in Arumeru and Karatu districts, Tanzania. Information sought included the capacity to offer TB service and availability of qualified staff and equipment for TB diagnosis. Information on availability and utilization of TB registers and treatment outcome for the year 2004 were also collected. A total of 111 health facilities were surveyed, 86 (77.5%) in Arumeru and 25 (22.5%) in Karatu. Only 23.4% (26/111) facilities were offering TB treatment services in the two districts. Majority 17/26 (65.38%) of them were government owned. Thirty eight (44.7%) facilities were offering TB laboratory services. All facilities with TB services (TB laboratory investigation and treatment) had TB registers. Seventy two (85.0%) of health facilities which do not provide any TB services had qualified clinical officers and at least a microscopy. Of the 339 cases notified in Arumeru in 2004, 187 (60.7%) had treatment outcome available, 124 (66.3%) were cured and 55 (29.4%) completed treatment. In Karatu 638 cases were notified in 2004, 305 (47.8%) had treatment outcome available, 68 (22.3%) cured and 165 (54.1%) completed treatment. In conclusion, the overall capacity for implementing DOTS among the facilities surveyed is found only in about 20% and 30% for clinical and laboratory components of DOTS, respectively. The capacity to provide TB diagnosis and treatment in Karatu district was relatively lower than Arumeru. It is important that capacity of the facilities is strengthened concurrently with the planned introduction of community-based DOTS in Tanzania.

Tuberculosis Trends, Vietnam

Tuberculosis Trends, Vietnam

Estudo descritivo sobre a implantação da estratégia de tratamento de curta duração diretamente observado no controle da tuberculose em São José do Rio Preto e seus impactos (1998-2003)

To describe treatment outcomes (cure, noncompliance or death) after the implementation of the Directly Observed Treatment, Short-course (DOTS) strategy for tuberculosis control in the city of São José do Rio Preto, Brazil, between 1998 and 2003. A descriptive study, based on secondary data (National Case Registry database, Tuberculosis Epidemiology database, and the 'Black Book' Registry), was conducted using a specific instrument. The data were analyzed using descriptive statistics. After the implementation of the DOTS strategy, there was a decrease in noncompliance and case detection rates as well as an increase in cure and death rates. The increase in the number of tuberculosis-related deaths might be attributable to three factors: the predominance of the disease in individuals over 50 years of age, tuberculosis/HIV co-infection, and the presence of accompanying diseases. The implementation of the DOTS strategy strengthened the decentralization of the tuberculosis control plans as well as the integration of the Basic Health Care Clinic teams with the Tuberculosis Control Program team. Political commitment of the administrator to tuberculosis control, in conjunction with the policy of benefits and incentives, is essential for the sustainability of the DOTS strategy.

Current epidemiological aspects of tuberculosis and the impact of the DOTS strategy in disease control

This article aims to present the current situation of tuberculosis and how the DOTS (Directly Observed Treatment Short Course) strategy has impacted national tuberculosis control programs worldwide, in Latin America and in Brazil. Data reveal a tendency towards a slow decline in disease rates (1%) around the world in 2003. In Brazil, data indicate a constant downward tendency of approximately 3% a year in incidence levels. The DOTS strategy has been recommended to all countries. Brazil needs to improve its tuberculosis surveillance efforts, particularly in terms of confirming negative sputum smear results at the end of treatment.

Treatment outcome of TB/HIV positive and TB/HIV negative patients on directly observed treatment, short course (DOTS) in Sagamu, Nigeria

The World Health Organisation marked 10 years of implementation of Directly Observed Treatment short course (DOTS). One key factor affecting the success of the DOTS strategy is the rising HIV prevalence among TB patients. The study was embarked upon to compare the treatment outcome of TB/HIV positive and TB/HIV negative patients in Sagamu, Nigeria. A prospective study of 353 smear positive TB patients aged 15 years and above who were registered for 8 months anti-tuberculosis (DOTS) therapy between January 2001 and December 2003 at the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria. Treatment outcome indicators of cure, default, transfer to another district and death were assessed in relation to the HIV status of the patients. There were 353 eligible patients of which 58 (16.4%) were HIV positive. The clinical symptoms and signs of TB were similar in both HIV positive and negative TB patients. The cure rate was 76.8%.patients. The cure rate was significantly lower in HIV infected compared with non-HIV infected TB patients (60.3% v 80.0%;p = 0.0001). However, among survivors it was not significant (71.4% v 82.5%; p = 0.07). Overall mortality was 5.1% which was significantly higher in HIV positive compared to HIV negative TB patients (15.5% v 3.1%; p = 0.00007). On the whole, 17% defaulted treatment and 1.1% failed treatment. These were however not significantly related to HIV status. The cure rate in this study is still lower than the recommended 85% target by the WHO. Mortality rate in TB/HIV positive patients was higher than in HIV negative patients. The option of a community based TB programme using volunteers or family members to supervise administration of anti-TB drugs so as to ensure adherence to TB treatment may be considered.

Tuberculosis Recurrence and Mortality after Successful Treatment: Impact of Drug Resistance

BackgroundThe DOTS (directly observed treatment short-course) strategy for tuberculosis (TB) control is recommended by the World Health Organization globally. However, there are few studies of long-term TB treatment outcomes from DOTS programs in high-burden settings and particularly settings of high drug resistance. A DOTS program was implemented progressively in Karakalpakstan, Uzbekistan starting in 1998. The total case notification rate in 2003 was 462/100,000, and a drug resistance survey found multidrug-resistant (MDR) Mycobacterium tuberculosis strains among 13% of new and 40% of previously treated patients. A retrospective, observational study was conducted to assess the capacity of standardized short-course chemotherapy to effectively cure patients with TB in this setting.Methods and FindingsUsing routine data sources, 213 patients who were sputum smear-positive for TB, included in the drug resistance survey and diagnosed consecutively in 2001–2002 from four districts, were followed up to a median of 22 months from diagnosis, to determine mortality and subsequent TB rediagnosis. Valid follow-up data were obtained for 197 (92%) of these patients. Mortality was high, with an average of 15% (95% confidence interval, 11% to 19%) dying per year after diagnosis (6% of 73 pansusceptible cases and 43% of 55 MDR TB cases also died per year). While 73 (74%) of the 99 new cases were “successfully” treated, 25 (34%) of these patients were subsequently rediagnosed with recurrent TB (13 were smear-positive on rediagnosis). Recurrence ranged from ten (23%) of 43 new, pansusceptible cases to six (60%) of ten previously treated MDR TB cases. MDR M. tuberculosis infection and previous TB treatment predicted unsuccessful DOTS treatment, while initial drug resistance contributed substantially to both mortality and disease recurrence after successful DOTS treatment.ConclusionsThese results suggest that specific treatment of drug-resistant TB is needed in similar settings of high drug resistance. High disease recurrence after successful treatment, even for drug-susceptible cases, suggests that at least in this setting, end-of-treatment outcomes may not reflect the longer-term status of patients, with consequent negative impacts for patients and for TB control.

Sharing the burden of TB/HIV? Costs and financing of public–private partnerships for tuberculosis treatment in South Africa

To explore the economic costs and sources of financing for different public-private partnership (PPP) arrangements to tuberculosis (TB) provision involving both workplace and non-profit private providers in South Africa. The financing required for the different models from the perspective of the provincial TB programme, provider, and the patient are considered. Two models of TB provider partnerships were evaluated, relative to sole public provision: public-private workplace (PWP) and public-private non-government (PNP). The cost analysis was undertaken from a societal perspective. Costs were collected retrospectively to consider both the financial and economic costs. Patient costs were estimated using a retrospective structured patient interview. Expansion of PPPs could potentially lead to reduced government sector financing requirements for new patients: government financing would require $609-690 per new patient treated in the purely public model, in contrast to PNP sites which would only need to $130-139 per patient and $36-46 with the PWP model. Moreover, there are no patient costs associated with the treatment in the employer-based facilities and the cost to the patient supervised in the community is, on average, three times lower than in public sector facilities. The results suggest that there is a strong economic case for expanding PPP involvement in TB treatment in the process of scaling up. The cost to the government per new patient treated could be reduced by enhanced partnership between the private and public sectors.

Failure of Directly Observed Treatment for Tuberculosis in Africa: A Call for New Approaches

The tuberculosis pandemic continues to evolve. In some parts of the world tuberculosis case rates have decreased to historically low levels whereas in other parts of the world the incidence of tuberculosis is increasing. In sub-Saharan Africa tuberculosis continues to be a major threat to individual and public health as incidence rates surpass 1000 cases per 100000 population in some regions. In 1994 the World Health Organization (WHO) declared tuberculosis a global emergency and introduced the directly observed treatment short course (DOTS) strategy for global tuberculosis control but the plan has produced variable success. In the face of this intensified effort to diagnose and treat tuberculosis the rates in sub-Saharan Africa continue to climb. Various experts have argued that the failure of the DOTS strategy to control tuberculosis results from failed implementation poor public health infrastructure poverty the lack of interventions that are sensitive to personal preferences and the HIV epidemic. Although each of these reasons may contribute the problem with the DOTS strategy may be even more fundamental. What is the rationale for the DOTS strategy? Is it a public health intervention designed to curb the spread of tuberculosis or is it a treatment guideline for tuberculosis? (excerpt)

Impact of HIV Infection on the Epidemiology of Tuberculosis in a Peri-Urban Community in South Africa: The Need for Age-Specific Interventions

In August 2005, the World Health Organization declared the tuberculosis (TB) epidemic in Africa to be a regional emergency. Current TB-control measures are failing, largely as a result of the human immunodeficiency virus (HIV) epidemic. Evaluation of additional control interventions requires detailed understanding of the epidemiological relationship between these diseases at the community level. We examined age- and sex-specific trends in TB notifications and their association with the prevalence of HIV infection in a peri-urban township in South Africa during 1996-2004. Denominators for TB notifications were derived from population census data. The local TB-control program used the World Health Organization directly observed treatment, short-course (DOTS) strategy. TB notification rates increased 2.5-fold during the period, reaching a rate of 1468 cases per 100,000 persons in 2004 (P=.007, by test for trend); the estimated population prevalence of HIV infection increased from 6% to 22% during the same period. After stabilization of prevalence of HIV infection, the TB notification rate continued to increase steeply, indicating ongoing amplification of the TB epidemic. In 2004, at least 50% of children aged 0-9 years who developed TB were HIV infected. Annual TB notification rates among adolescents increased from 0 cases in 1996-1997 to 436 cases per 100,000 persons in 2003-2004, and these increases were predominantly among female. However, 20-39-year-old persons were affected most, with TB notification rates increasing from 706 to 2600 cases per 100,000 persons among subjects in their 30s. In contrast, TB rates among persons aged >50 years did not change. HIV infection is driving the TB epidemic in this population, and use of the DOTS strategy alone is insufficient. TB notifications have reached unprecedented levels, and additional targeted, age-specific interventions for control of TB and HIV infection in such populations are needed.