HIV This Week

Hesseling AC, Cotton MF, Fordham von Reyn C, Graham SM, Gie RP, Hussey GD. Consensus statement on the revised World Health Organization recommendations for BCG vaccination in HIV-infected infants: Submitted on behalf of the BCG Working Group, Child Lung Health Section, International Union Against Tuberculosis and Lung Disease, 38th Union World Conference on Lung Health, Cape Town, 8-12 November 2007. Int J Tuberc Lung Dis. 2008;12(12):1376-1379.

This document outlines the consensus agreement from the Union’s BCG Working Group regarding BCG vaccination in HIV-infected infants, in response to recently revised World Health Organization (WHO) guidelines, which make HIV infection in infants a full contraindication to bacille Calmette-Guérin (BCG) vaccination. BCG is one of the most widely given vaccines globally and is safe in immunocompetent individuals. Recent evidence shows that HIV-infected infants who were routinely vaccinated with BCG at birth, when asymptomatic, and who later developed AIDS, are at high risk of developing disseminated BCG disease (estimated incidence 407-1300 per 100 000). The document outlines requirements to implement selective BCG vaccination strategies in infants born to HIV-infected women and strategies to reduce the risk of vertical HIV transmission and disseminated BCG disease in infants.

Editors’ note: Although BCG vaccination has a summary estimate protective effect of 73% against tuberculosis meningitis and 77% against miliary disease, there is no evidence of any BCG-induced protective effect in HIV-infected children. Furthermore, they face a higher risk of disseminated BCG disease, which is associated with all-cause mortality in excess of 75%. BCG vaccination in these children is therefore contraindicated. However, the majority of infants born to mothers living with HIV are not HIV infected. A selective BCG vaccination policy in HIV-exposed infants will require high uptake of maternal HIV testing, strengthened prevention of mother-to-child transmission services, and better integration of TB and HIV programmes.

HIV and HIV-tuberculosis (TB) co-infection are slowly increasing in Indonesia. WHO recommends HIV testing among TB patients as a key response to the dual HIV-TB epidemic. Concerns over potential negative impacts to TB control and lack of operational clarity have hindered progress. Mahendradhata and colleagues investigated the barriers and opportunities for introducing HIV testing perceived by TB patients and providers in Jogjakarta, Indonesia. They offered voluntary counselling and testing to TB patients in parallel to a HIV prevalence survey. The authors conducted in-depth interviews with 33 TB patients, 3 specialist physicians and 3 disease control managers, as well as four focus group discussions with nurses. All interviews and focus group discussions were recorded and data analysis was supported by the QSR N6® software. Patients’ and providers’ knowledge regarding HIV was poor. The main barriers perceived by patients were: burden for accessing voluntary counselling and testing and fear of knowing the test results. Stigma caused concerns among providers, but did not play much role in patients’ attitude towards voluntary counselling and testing. The main barriers perceived by providers were communication, patients feeling offended, stigmatization and additional burden. Introduction of HIV testing among TB patients in Indonesia should be accompanied by patient and provider education as well as providing conditions for effective communication.

Editors’ note: Learning local stakeholders’ perspectives is key to planning and implementing services that work for people. In this setting, the length of the testing and counselling, the need to return to an external site to get test results, and the perception of not being at risk deter most TB patients from an HIV test. More effective patient-provider communication in the context of a same day, same site offer/recommendation of HIV testing to all TB patients is warranted in Indonesia, which ranks third in the world for TB burden and has low but increasing HIV prevalence.