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) epide mic on tuberculosis (TB) has been evaluated for certain countries in s ub-Saharan Africa. However, no multi-country comparisons have been per formed 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 t hese changes. Methods: We examined trends in TB case rates after 1985 for 20 sub-Saharan African countries, and also from 1975-1984 for 10 o f these countries (core countries). Average annual changes in TB case rates after 1985 were stratified by 1992 urban low-risk HN seroprevale nce and by NTP quality, as determined by a survey of international TB experts. Results: Case rates in the core countries decreased by an ave rage of -1.6% per year prier to 1985, but increased by an average of 7.0% per year after 1985 (+7.7% per year after 1985 in all 20 countrie s). Average annual case rates after 1985 increased approximately twice as fast in countries with high vs low or intermediate HIV seroprevale nce ratings. In both the core countries and all 20 countries, the aver age annual rate of rise in case rates after 1985 decreased as NTP qual ity rating increased. This relationship persisted even after stratific ation by HN seroprevalence rating. Conclusions: TB case rates have inc reased in sub-Saharan Africa since 1985. These increases were relative ly greater as HIV seroprevalence increased, and relatively lower as NT P quality increased. Improving NTP quality is essential to mitigate th e resurgence of TB in the HIV era.