Human Immunodeficiency Virus Epidemic Control Research Articles

Model-Informed Targeted Network Interventions on Social Networks Among Men Who Have Sex With Men in Zhuhai, China

Men who have sex with men (MSM) are at disproportionally high risk for human immunodeficiency virus (HIV) infection in China. The increasing HIV prevalence among MSM highlights the urgent need for effective prevention interventions among MSM. Interventions targeted at individuals who are highly vulnerable to HIV infection have been proven effective in reducing incidence rates. However, existing targeted interventions are limited to small-scale programs. To investigate the effectiveness of large-scale targeted network interventions in real-world settings, we build a stochastic agent-based network model informed by the comprehensive online social networking and dating behavior data and epidemiological data among MSM in Zhuhai, China. With the proposed model, we simulate HIV transmissions and compare the efficacy of different targeted intervention programs. We propose a new method, namely, RiskRank, to prioritize nodes for targeted interventions by incorporating: 1) their topological features on the online social network; 2) the underlying epidemic dynamics; and 3) the position of identified HIV-infected individuals on the sexual network. Results show that the targeted interventions are more effective than random interventions in large-scale HIV epidemic control. The proposed RiskRank method consistently outperforms state-of-the-art baselines in various intervention scenarios.

Fast-track interventions for HIV and AIDS epidemic control among key populations: A rapid review.

Targeted interventions for key populations remain critical for realisation of epidemic control for human immunodeficiency virus (HIV) infection because of the causal relationship between HIV infection in the general population and among key population groups. To consolidate evidence on the fast-track interventions towards achieving HIV epidemic control among key populations. A rapid scoping review was conducted using the methodological framework by Arksey and O' Malley. The Population, Intervention, Context and Outcome (PICO) framework was used to identify relevant studies using key words with Boolean operators in electronic data bases, namely CINHAL, Web of Science, Psych Info and Sabinet. Studies were extracted using a modified data extraction tool, and results were presented narratively. A total of 19 articles were included in this review. Most articles were primary studies (n = 17), while another involved the review of existing literature and policies (n = 2) and routinely collected data (n = 1). Most studies were conducted in the United States of America (n = 6), while another were conducted in China, Kenya, Botswana, South Africa and Mozambique. All studies revealed findings on tested interventions to achieve HIV epidemic control among key populations. Effective interventions for HIV epidemic control were stand-alone behavioural preventive interventions, stand-alone biomedical preventive strategies and combination prevention approaches. Furthermore, the findings suggest that effective activities to achieve HIV epidemic control among key populations should be centred around prevention.Contribution: The findings of this study have policy and practice implications for high HIV burden settings such as South Africa in terms of interventions to facilitate realisation of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets, thereby contributing to HIV epidemic control.

Investigating the Relationship between Medication Adherence Behaviors and the Achievement of Sustained Viral Load Suppression among People Living with HIV (PLHIV) on Antiretroviral Therapy (ART) in Akwa Ibom State, from 2018 - 2022

Background: Nigeria is still endemic for Human Immuno-Deficiency Virus (HIV), and currently among the top five countries with the highest burdens of HIV infection. For a successful HIV program, there should be good access to antiretroviral therapy (ART) and record of viral load suppression (VLS). This study aimed at investigating the relationship between medication adherence behavior (MAB) and sustained VLS among people living with HIV (PLHIV) receiving ART in Akwa Ibom State. Methods: This was a retrospective cohort study of the medical records of 1,763 PLHIV receiving ART services from January 2018 to December 2022, in selected ten health facilities in Akwa Ibom State. Relevant demographic, clinical, immunological, viral load (VL) information were obtained from the patients’ medical records and databases. The proportion of VLS and associated variables were then analyzed. Results: Out of the 2,550 PLHIV whose medical records were accessed, data for 1,763 PLHIV was accepted for analysis. A total of 795 (45.1%) male and 968 (54.9%) female participated in the study, with a mean age of 38.4 ± 5 years. While 23.8% (n = 420) have unsuppressed VL of >1,000 copies/mL; 76.2% (n = 1,343) of participants achieved VLS of <1,000 copies/mL. 90.4% (n = 1,213) of the virally suppressed participants recorded moderate to high medication adherence levels (X2 = 94.977, df = 2, p-value = 2.2 x 10-16). CD4 counts and HAART regimen have significant impact on VLS (p < 0.05), while pregnancy status, TB Infection, duration on HAART, and WHO disease stage do not have significant effects on VLS (p > 0.05). Conclusion: There was a strong evidence to reject the null hypothesis, which states that there is no positive association between MAB and sustained VLS among PLHIV on ART (p < 0.05). The VLS rate in this study indicates a good HIV epidemic control. Good medication adherence level, high baseline CD4 count, and being on first line HAART regimen were strongly associated with VLS.

Access to HIV prevention, treatment, and care services during COVID-19 by men who have sex with men in Zimbabwe, An interpretive phenomenological analysis study.

Key populations are disproportionately affected by the human immunodeficiency virus (HIV) but have less access to HIV prevention and treatment services. The Coronavirus disease-2019 (COVID-19) pandemic is reinforcing health inequities among vulnerable populations, including men who have sex with men (MSM). Therefore, this article presents the findings describing the experiences of MSM in accessing HIV services during COVID-19 in the second largest city of Zimbabwe. An interpretative phenomenological analysis design was applied to gain some insights regarding the lived experiences of MSM in accessing HIV prevention, treatment, and care services during COVID-19 lockdowns era in Zimbabwe. Data were collected from 14 criterion purposively selected MSM using in-depth, one-on-one interviews. Data were analysed thematically guided by the interpretative phenomenological analysis framework for data analysis. The findings demonstrated that during the COVID -19 lockdowns in Zimbabwe, MSM faced several barriers as they tried to access HIV services. Some of the barriers included the need for travel authorisation letters and treatment interruption. The study also found that COVID-19 and related restrictive measures had psychosocial and economic effects that encompassed loss of income, intimate partner violence and psychological effects. Limited access to healthcare services by MSM due to COVID-19 lockdown may negatively affect the viral suppression and fuel the spread of HIV, which may reverse the gains toward the control of HIV epidemic. To sustain the gains toward HIV epidemic control and to ensure continuity of treatment, particularly for members of key populations, it is critical that the health-care delivery system adjusts by taking service to the community through adopting a differentiated service delivery approach.

Hazardous alcohol use and HIV indicators in six African countries: results from the Population-based HIV Impact Assessments, 2015-2017.

Hazardous alcohol use (HAU), defined as a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others, is associated with an elevated risk of human immunodeficiency virus (HIV) infection and poor health outcomes. We describe the association between people living with HIV (PLHIV) who report HAU and key HIV indicators. Gaps in current literature in estimating HAU on HIV outcomes at the regional level of Eastern and Southern Africa still exist and our analysis aims to address this issue. We used weighted pooled data (2015-2017) from the nationally representative Population-based HIV Impact Assessments among adults who provided written consent aged 18-59 years from Eswatini, Malawi, Namibia, Tanzania, Zambia and Zimbabwe. We estimated differences in the prevalence of HIV infection and The Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 indicators between PLHIV by HAU status using log-binomial regression, stratified by sex.HAU was determined using the Alcohol Use Identification Test-Consumption. Among the 9755 women and 4444 men who tested HIV positive, 6.6% of women and 21.8% of men engaged in HAU. Women who reported HAU were more likely to be HIV positive (adjusted prevalence ratio [aPR] = 1.31, 95% CI: 1.18-1.46) compared to those who did not report HAU. For the UNAIDS 90-90-90 targets, women who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.22, 95% CI: 1.01-1.47) and not on antiretroviral therapy (ART) (aPR = 1.73, 95% CI: 1.26-2.37). Men who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.56, 95% CI 1.39-1.76) and not on ART (aPR = 1.72, 95% CI: 1.30-2.29). No difference in viral load suppression, defined as <1000 copies/ml of HIV RNA, was seen by sex. PLHIV who engage in HAU were more likely to have suboptimal outcomes along the HIV care continuum when compared to those who did not engage in HAU. Targeted interventions, such as alcohol screening for HAU in HIV testing and treatment settings and HIV prevention efforts in alcohol-based venues, may help countries reach HIV epidemic control by 2030.

Utilisation of HIV services by female sex workers in Zimbabwe during the COVID-19 pandemic: a descriptive phenomenological study

This study focuses on female sex workers as a key population group that suffers a degree of vulnerability according to the World Health Organisation (WHO). Key populations refer to people at heightened risk of contracting the human immunodeficiency virus (HIV) due to specific behaviours and social and legal environments which increase their vulnerability to the virus. Key populations are disproportionately affected by HIV, yet they have less access to HIV services compared to the general population. The coronavirus (COVID-19) lockdown and its restrictive measures have further widened the inequalities and gaps in accessing HIV services for this group. A descriptive phenomenological study was undertaken to explore female sex workers’ experiences of utilisation of HIV services during COVID-19. The study setting was the Bulawayo Metropolitan Province, Zimbabwe. Data were collected through in-depth individual interviews with 10 female sex workers. Purposive sampling coupled with snowballing was utilised for recruiting participants. Data were analysed guided by the seven-step Colaizzi technique. Rigour was ensured through adhering to Lincoln and Guba’s trustworthiness criteria. The study found that the COVID-19 pandemic adversely affected the livelihoods of sex workers and their utilisation of HIV services. There was limited access to HIV services due to an initial lack of travel authorisation letters and financial challenges experienced by study participants. In addition, the quality of care in health care facilities was further compromised by poor screening processes and reduced provider-client interactions. Maintaining access to HIV services for female sex workers during pandemics is critical for the country to attain HIV epidemic control.

Tanzania HIV Investment Case (IC) 2.0: Using modeling to explore optimization under severe resource constraints

Background After years of increased human immunodeficiency virus (HIV) investments in Tanzania, the United States Presidents Emergency Program for the AIDS Response (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) have signaled that their financing will plateau or decline in the coming years, despite remaining challenges to reaching the Fast-Track 95-95-95 goals. To plan for these challenges, the Tanzania Ministry of Health and local partners requested an update to the country’s HIV investment case, recognizing that domestic financing will also be severely constrained over the coming decade. Methods Using the Goals model, five program scenarios (2019-30) were modeled and their health impacts and costs compared. Two scenarios were coverage-driven, Constant Coverage (CC) and the National Strategy (NS) while the three remaining scenarios explored how limited resources could be optimized through prioritization of prevention interventions, raising efficiency of treatment, and expanding cost-effective testing modalities. The resource envelopes used for resource-constrained scenarios were: same funding as the CC scenario, declining donor funds, and declining donor funds offset by domestic resource mobilization. Results Implementing the NS is estimated to cost US$8.1 billion over 2019-30, a 40% increase over the CC scenario. If the same funds needed to maintain CC were optimized, the NS goals could be achieved for US$2.5 billion less. If donor funds decline and domestic funding is not mobilized, even with optimization new HIV infections would increase by 7% and acquired immunodeficiency syndrome (AIDS)-related deaths by 24%. However, if the government can mobilize an average year on year increase of US$10.8 million, optimization would allow the country to achieve its ambitious Fast-Track goals. Conclusions If donor funds for HIV decline as announced, the Government needs to proactively optimize the response and invest more domestic resources to compensate, in order to achieve HIV epidemic control. Otherwise, national goals could be compromised. Other high burden countries can consider a similar investment case approach in the current era of fiscal constraints, which have been further exacerbated by COVID-19.

The lived experiences of men who have sex with men when accessing HIV care services in Zimbabwe.

BackgroundKey populations such as men who have sex with men are disproportionately affected by human immunodeficiency virus (HIV), yet they are underserved. This vulnerable group also faces stigma and discrimination when utilising the healthcare services. However, to achieve the HIV epidemic control, it is important for them to have access to HIV care services.AimThe aim of this study was to explore and describe the experiences of men who have sex with men (MSM) as they accessed HIV care services in healthcare settings in Bulawayo, Zimbabwe.SettingThe study setting was healthcare facilities (state and private owned) in Bulawayo, Zimbabwe, that offer HIV care services.MethodsThe study used a descriptive phenomenological design targeting self-identified MSM living with HIV. Data were gathered by using in-depth individual interviews that were audio recorded. Data saturation determined sample size. Data were transcribed verbatim and later analysed thematically.ResultsThe study revealed that counselling given to MSM was generalised and not individualised. Some clients faced stigma and discrimination after disclosure. Peer and family support were important in the journey to access HIV care services.ConclusionAn enabling environment was not provided for MSM clients to access HIV care services in the majority of health facilities. This calls for sensitisation and competency clinical training of service providers so that the diverse needs of MSM are met. Peer and family support for MSM needs to be strengthened.

Human Immunodeficiency Virus Continuum of Care in 11 European Union Countries at the End of 2016 Overall and by Key Population: Have We Made Progress?

BackgroundHigh uptake of antiretroviral treatment (ART) is essential to reduce human immunodeficiency virus (HIV) transmission and related mortality; however, gaps in care exist. We aimed to construct the continuum of HIV care (CoC) in 2016 in 11 European Union (EU) countries, overall and by key population and sex. To estimate progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, we compared 2016 to 2013 estimates for the same countries, representing 73% of the population in the region.MethodsA CoC with the following 4 stages was constructed: number of people living with HIV (PLHIV); proportion of PLHIV diagnosed; proportion of those diagnosed who ever initiated ART; and proportion of those ever treated who achieved viral suppression at their last visit.ResultsWe estimated that 87% of PLHIV were diagnosed; 92% of those diagnosed had ever initiated ART; and 91% of those ever on ART, or 73% of all PLHIV, were virally suppressed. Corresponding figures for men having sex with men were: 86%, 93%, 93%, 74%; for people who inject drugs: 94%, 88%, 85%, 70%; and for heterosexuals: 86%, 92%, 91%, 72%. The proportion suppressed of all PLHIV ranged from 59% to 86% across countries.ConclusionsThe EU is close to the 90-90-90 target and achieved the UNAIDS target of 73% of all PLHIV virally suppressed, significant progress since 2013 when 60% of all PLHIV were virally suppressed. Strengthening of testing programs and treatment support, along with prevention interventions, are needed to achieve HIV epidemic control.

Population prevalence of sexually transmitted infections in a high HIV burden district in KwaZulu-Natal, South Africa: Implications for HIV epidemic control

BackgroundSexually transmitted infections (STIs) and Human immunodeficiency virus (HIV) share a complex bidirectional relationship, however, population prevalence and the association between the presence of STIs and HIV in a high HIV burden district in KwaZulu-Natal, South Africa is not known. MethodsA total of 9812 participants aged 15–49 years were enrolled in a cross-sectional population-based household survey. Participants completed a structured questionnaire and provided first-pass urine (males) or self-collected vulvo-vaginal swabs (females) for the detection of STIs. ResultsPrevalence of herpes simplex virus type-2 (HSV-2) was 57.8%, syphilis was 1.6%, Neisseria gonorrhoeae was 2.8%, Chlamydia trachomatis was 7.1%, Trichomonas vaginalis was 9.0%, Mycoplasma genitalium was 5.5% and HIV was 36.3%. HIV positive status was associated with an increased probability of having M. genitalium (aPR = 1.49, 95% CI 1.02–2.19) among males and syphilis (aPR = 2.54, 95% CI 1.32–4.86), N. gonorrhoeae (aPR = 2.39, 95% CI 1.62–3.52), T. vaginalis (aPR = 1.70, 95% CI 1.43–2.01) and M. genitalium (aPR = 1.60, 95% CI 1.15–2.22) among females. HIV viral load ≥400 copies per mL was associated with an increased probability of N. gonorrhoeae (aPR = 1.91, 95% CI 1.36–2.70), C. trachomatis (aPR = 1.52, 95% CI 1.12–2.05) and M. genitalium (aPR = 1.83, 95% CI 1.27–2.63). ConclusionsThe high prevalence of STIs and the association between STIs and HIV, and HIV viral load underscores the public health implications of sustained transmission risk of STIs and HIV. These findings highlight the urgent need for expanding STI surveillance and implementing interventions to monitor and reduce the STI burden.

Understanding the Reasons for Sharing Syringes or Needles to Inject Drugs: Conventional Content Analysis.

BackgroundThis qualitative study was undertaken with the aim to identify the reasons for sharing syringes or needles among people who inject drugs (PWID) in Iran.MethodsWe used purposive sampling to recruit 4 groups of participants, male PWID (n = 14), female PWID (n = 6), service providers (n = 8), and human immunodeficiency virus (HIV)/addiction experts (n = 9). Data were collected through 2 focus group discussions (FGDs) among male PWID, and semi-structured interviews with female PWID, service providers, and HIV/addiction experts. Using conventional content analysis, themes were extracted for reasons for sharing needles to inject drugs.FindingsWe found 13 themes for barriers such as low perceived risk of HIV, high stigma around drug injection and use, low access to harm reduction education and prevention services due to their limited working hours as a well as uneven geographical distribution of services, some structural barriers like incarceration, poverty, and homelessness, and several competing survival needs beyond the injection-related safe behaviors.ConclusionOur study was able to provide the perspectives of both PWID and health care authorities and providers towards several barriers to accessing HIV prevention services that lead to needle sharing among PWID in Iran. These barriers need to be addressed to achieve the target of HIV epidemic control.

A multi-institutional, cross-sectional study on disclosure of HIV status to sexual partner(s) and associated factors among people living with HIV/AIDS attending selected hospitals in Kigali, Rwanda

Background: In Sub-Saharan Africa, human immunodeficiency virus (HIV) remains a public health problem. There is need for evidence-based interventions to curb new infections. HIV status disclosure, especially to sexual partner(s) remains a critical step towards reducing viral transmission across sexual partners.Methods: A hospital-based cross-sectional study, conducted at HIV clinics of three selected hospitals. Systematic random sampling was employed to sample 384 people living with HIV/AIDS (PLWH). A pre-tested self-administered questionnaire was used to collect data.Results: Of the participants, 66% of the participants reported HIV positive status disclosure, with only 46% of these having disclosed to their sexual partner. Logistic regression analysis identified age (p value 0.035; AOR 0.94), being satisfied with counselling (p value 0.017; AOR 0.24), gender (p value 0.030; AOR 5.51) and education (p value 0.041; AOR 2.14) as factors associated with having disclosed HIV status. Being younger, satisfaction with counselling, being female and having attained at least secondary education were all associated with higher odds of HIV status disclosure.Conclusions: Based on the findings of the current study, it can be concluded that there is need to improve rates of HIV status disclosure among PLWH in Kigali, Rwanda. The current study findings have provided baseline information for the local health authorities, health care providers, policy makers and other scholars working in HIV epidemic control. The local health authorities can use this as a guide to develop a programme aimed to address the issue of non-disclosure of HIV status in Kigali City and hence help control the incessant spread of HIV infection.

Tailored HIV programmes and universal health coverage

Improvements in geospatial health data and tailored human immunodeficiency virus (HIV) testing, prevention and treatment have led to greater microtargeting of the HIV response, based on location, risk, clinical status and disease burden. These approaches show promise for achieving control of the HIV epidemic. At the same time, United Nations Member States have committed to achieving broader health and development goals by 2030, including universal health coverage (UHC). HIV epidemic control will facilitate UHC by averting the need to commit ever-increasing resources to HIV services. Yet an overly targeted HIV response could also distort health systems, impede integration and potentially threaten broader health goals. We discuss current approaches to achieving both UHC and HIV epidemic control, noting potential areas of friction between disease-specific microtargeting and integrated health systems, and highlighting opportunities for convergence that could enhance both initiatives. Examples of these programmatic elements that could be better aligned include: improved information systems with unique identifiers to track and monitor individuals across health services and the life course; strengthened subnational data use; more accountable supply chains that supply a broad range of services; and strengthened community-based services and workforces. We argue that the response both to HIV and to broader health threats should use these areas of convergence to increase health systems efficiency and mitigate the harm of any potential decrease in health funding. Further investments in implementation and monitoring of these programme elements will be needed to make progress towards both UHC and HIV epidemic control.

Human Immunodeficiency Virus Epidemic Control in the United States: An Assessment of Proposed UNAIDS Metrics, 2010-2015.

Epidemic control is necessary to eliminate human immunodeficiency virus infections. We assessed epidemic control in the United States by applying 4 proposed UNAIDS metrics to national surveillance data collected between 2010 and 2015. Although epidemic control in the United States is possible, progress by UNAIDS metrics has been mixed.

Status of HIV Epidemic Control Among Adolescent Girls and Young Women Aged 15-24 Years - Seven African Countries, 2015-2017.

In 2016, an estimated 1.5 million females aged 15-24 years were living with human immunodeficiency virus (HIV) infection in Eastern and Southern Africa, where the prevalence of HIV infection among adolescent girls and young women (3.4%) is more than double that for males in the same age range (1.6%) (1). Progress was assessed toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2020 targets for adolescent girls and young women in sub-Saharan Africa (90% of those with HIV infection aware of their status, 90% of HIV-infected persons aware of their status on antiretroviral treatment [ART], and 90% of those on treatment virally suppressed [HIV viral load <1,000 HIV RNA copies/mL]) (2) using data from recent Population-based HIV Impact Assessment (PHIA) surveys in seven countries. The national prevalence of HIV infection in adolescent girls and young women aged 15-24 years, the percentage who were aware of their status, and among those persons who were aware, the percentage who had achieved viral suppression were calculated. The target for viral suppression among all persons with HIV infection is 73% (the product of 90% x 90% x 90%). Among all seven countries, the prevalence of HIV infection among adolescent girls and young women was 3.6%; among those in this group, 46.3% reported being aware of their HIV-positive status, and 45.0% were virally suppressed. Sustained efforts by national HIV and public health programs to diagnose HIV infection in adolescent girls and young women as early as possible to ensure rapid initiation of ART should help achieve epidemic control among adolescent girls and young women.

HIV epidemic control—a model for optimal allocation of prevention and treatment resources

With 33 million people living with human immunodeficiency virus (HIV) worldwide and 2.7 million new infections occurring annually, additional HIV prevention and treatment efforts are urgently needed. However, available resources for HIV control are limited and must be used efficiently to minimize the future spread of the epidemic. We develop a model to determine the appropriate resource allocation between expanded HIV prevention and treatment services. We create an epidemic model that incorporates multiple key populations with different transmission modes, as well as production functions that relate investment in prevention and treatment programs to changes in transmission and treatment rates. The goal is to allocate resources to minimize R 0, the reproductive rate of infection. We first develop a single-population model and determine the optimal resource allocation between HIV prevention and treatment. We extend the analysis to multiple independent populations, with resource allocation among interventions and populations. We then include the effects of HIV transmission between key populations. We apply our model to examine HIV epidemic control in two different settings, Uganda and Russia. As part of these applications, we develop a novel approach for estimating empirical HIV program production functions. Our study provides insights into the important question of resource allocation for a country's optimal response to its HIV epidemic and provides a practical approach for decision makers. Better decisions about allocating limited HIV resources can improve response to the epidemic and increase access to HIV prevention and treatment services for millions of people worldwide.

Tuberculosis in sub-Saharan Africa: A regional assessment of the impact of the human immunodeficiency virus and National Tuberculosis Control Program quality

Background: The effect of the human immunodeficiency virus (HIV) epidemic on tuberculosis (TB) has been evaluated for certain countries in sub-Saharan Africa. However, no multi-country comparisons have been performed of the magnitude of the changes in TB case rates and the roles of the HIV epidemic and national TB control program (NTP) quality in these changes. Methods: We examined trends in TB case rates after 1985 for 20 sub-Saharan African countries, and also from 1975–1984 for 10 of these countries (core countries). Average annual changes in TB case rates after 1985 were stratified by 1992 urban low-risk HIV seroprevalence and by NTP quality, as determined by a survey of international TB experts. Results: Case rates in the core countries decreased by an average of −1.6% per year prior to 1985, but increased by an average of +7.0% per year after 1985 (+7.7% per year after 1985 in all 20 countries). Average annual case rates after 1985 increased approximately twice as fast in countries with high vs low or intermediate HIV seroprevalence ratings. In both the core countries and all 20 countries, the average annual rate of rise in case rates after 1985 decreased as NTP quality rating increased. This relationship persisted even after stratification by HIV seroprevalence rating. Conclusions: TB case rates have increased in sub-Saharan Africa since 1985. These increases were relatively greater as HIV seroprevalence increased, and relatively lower as NTP quality increased. Improving NTP quality is essential to mitigate the resurgence of TB in the HIV era.