Karukonda, Pooja

Arts and Sciences


South Africa

South Africa-When should sputum culture testing for active TB in HIV positive individuals take place?

The World Health Organization (WHO) recommends a sign and symptom screen e.g. cough of 2 week duration, as the trigger for tuberculosis screening in human immunodeficiency virus (HIV)–infected patients. An acid-fast bacillus (AFB) smear was the only recommended initial diagnostic test, prior to the introduction of the GeneXpert (which is still in the roll-out stage in South Africa). Researchers in Durban recently assessed the yield of intensive TB screening (including chest radiograph, sputum AFB and culture) in HIV infected individuals at the point of starting antiretroviral therapy. Patients (median CD4 count was 100 cells/ul) were enrolled regardless of tuberculosis signs and symptoms, and 20% were found to have undiagnosed culture-confirmed pulmonary tuberculosis. The conclusion from the study was that TB cultures should be performed on all HIV positive individuals prior to ART initiation. The K-RITH iThimba cohort, based at McCord Hospital in Durban, is currently enrolling HIV positive patients. 57 individuals out of a target 300 have been enrolled to date (with CD4 counts ranging from 119-1226 cells/ul). All patients have no signs and symptoms of TB at baseline and undergo comprehensive TB screening (including chest radiograph, sputum AFB and culture). Initial studies reported that patients with newly diagnosed HIV-associated TB had median CD4 counts (of 200–350 cells/_ l) which were generally higher than those in patients with other serious opportunistic infections. However, this has now sparked some controversy as more recent studies have reported much lower median CD4 counts (130-150 cells/ul) in newly diagnosed patients with HIV-associated TB. As HIV-1-infected individuals may display increased susceptibility to TB, even before their immune system is compromised to levels at which other opportunistic infections occur, we wish to assess the impact of comprehensive TB screening in our HIV positive ambulatory cohort. In addition as the vast majority of individuals in our cohort may have latent TB infection (LTBI), and that half of the cohort have been followed up every 3 months for a 1-year period, we wish to assess the impact of intensive TB screening (including mantoux skin test, TSPOT.TB, chest radiograph, sputum AFB and culture) to diagnose LTBI.nship description here.

I was very unsure of what to expect when I first found out that I would be spending my summer in South Africa. My expectations were largely informed by my exposure to American media and my knowledge of the country’s history—I thought of it as an impoverished nation still dealing with racial tensions from its past, and I was unsure of what the people would be like and how I would fit in or be treated. When I arrived in Durban, I was surprised to discover myself in a beautiful, modern, urban setting. Most surprising of all was the fact that everyone I encountered was unbelievably kind and eager to learn about me and my culture. The TB/HIV epidemic that South Africa faces became very real and personal to me as I interacted with the country’s people and learned how these issues affected them personally. Right away, I was inspired to do my part to help and contribute to this society that was so quick to welcome and accommodate me. 

During my internship in South Africa, I witnessed the tragic limitations of healthcare. It was deeply unsettling to see low-income patients in government hospitals who weren’t able to receive comprehensive, up-to-date care in a timely manner. For these patients, it took six weeks to obtain test results to confirm tuberculosis diagnosis, and since the drug resistance of the bacteria couldn’t be obtained until the test results came back, many patients could not receive the correct combination of medication in a timely fashion, leading to high mortality. Exacerbating this issue was a cultural stigma associated with going to the hospital. Most impoverished individuals opted to go to local tribal healers for medical care, a practice that was traditional to their culture. They only resorted to going to the hospital when the disease became advanced, and oftentimes it was too late, especially when the wait-times for determining diagnosis and bacterial resistance were factored in. The combination of logistical inadequacies in healthcare and a cultural stigma to medical treatment made battling a treatable disease like tuberculosis extremely difficult. This internship afforded me the opportunity to help make a real difference in the care that South Africans receive when infected with a dangerous infectious disease like tuberculosis. While abroad, I aided in the process of implementing a novel diagnostic protocol that could allow for more reliable diagnosis of pediatric tuberculosis. This experience has convinced me that with hard work and determination, I can serve a population that has limited resources and infrastructure and help them deal with serious yet solvable problems in healthcare. I also learned that for me, it is more meaningful and rewarding to provide service to those who were born in less fortunate circumstances. As a result of my internship, I have made the decision to devote my future career in medicine to the advancement of global health.

For any students who are prospective healthcare professionals with an interest in working abroad, I cannot stress enough the impact that a global health internship can have. I was given the chance to travel to parts of the world that I never would have seen and gain perspectives from people whom I never would have met. Being abroad also helped me consider myself within a new context, and learn more about who I am and who I want to be. This internship helped me grow as a person and helped me gain a better idea of what I’d like to do in the future, and I am very grateful for the opportunity that was given to me to travel and do meaningful research with amazing people.   


Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

December 2018



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