INT J TUBERC LUNG DIS 21(9):1008–1012 Q 2017 The Union http://dx.doi.org/10.5588/jtld.17.0103

Screening for latent tuberculous in people living with HIV infection in ,

N. Gow, S. Briggs, M. Nisbet Department of Infectious Diseases, Auckland City , Auckland, New Zealand

SUMMARY

SETTING: New Zealand, which has a low incidence of RESULTS: Of the 752 patients from the initial cohort, tuberculosis (TB), has historically taken a risk-based 416 (55%) had documentation of LTBI screening, which approach to screening for latent tuberculous infection was positive in 74 (10%): 19/461 (4%) low-risk and 55/ (LTBI) in adult people living with the human immuno- 291 (19%) high-risk patients. LTBI treatment was deficiency virus infection (PLHIV). received in 13 low-risk and 44 high-risk patients. Of OBJECTIVE: To evaluate LTBI screening, treatment and 73 patients in the second cohort, 68 (93%) were outcomes in an adult PLHIV population. screened. DESIGN: This was a retrospective clinical record review CONCLUSION: LTBI screening was incomplete in our of an initial cohort of adult PLHIV attending the clinic, but improved between 2011 and 2014. A Auckland City Hospital HIV clinic in 2011, and a significant number of patients with LTBI did not second cohort of adult PLHIV newly attending the clinic originate from a high TB incidence country. in 2014. We analysed high-risk (born in or acquiring KEY WORDS: PLHIV; high-income countries; screen- HIV in a high TB incidence country) and low-risk ing; IGRA patients using descriptive statistical methods.

TUBERCULOSIS (TB) IS A LEADING cause of notified with active TB disease and 3.5% of PLHIV morbidity and mortality in people living with the cared for at Auckland City Hospital (ACH).9 The human immunodeficiency virus infection (PLHIV).1 most recent New Zealand guidelines for TB control, Latent tuberculous infection (LTBI) is a state of from 2010, recommend that all adult PLHIV be persistent immune response to stimulation by Myco- screened for LTBI using the tuberculin skin test (TST) bacterium tuberculosis antigens with no evidence of or an interferon-gamma release assay (IGRA).10 The active TB disease.2 Following exposure to TB, PLHIV decision to screen for LTBI at ACH is at the discretion are at higher risk of developing LTBI and of of the treating physician. The QuantiFERONw-TB progressing from LTBI to active TB disease. Intensi- Gold (QFN; Cellestis Limited, Carnegie, VIC, Aus- fied TB case finding is one of the key World Health tralia) IGRA has been the preferred screening test for Organization (WHO) strategies to reduce the burden all adult PLHIV at ACH, regardless of CD4 count, of TB in PLHIV.3,4 LTBI treatment reduces the since its introduction in 2006. incidence of active TB disease among PLHIV, We aimed 1) to determine the extent of LTBI resulting in a 33% risk reduction for all PLHIV and screening for adult PLHIV attending the ACH HIV a 64% risk reduction in those with a positive LTBI clinic in 2011, 2) to review LTBI treatment and screening test.5 The most recent WHO guidelines on outcomes, and 3) to re-evaluate LTBI screening in the the management of LTBI in high- or upper middle- cohort of adult PLHIV newly attending the ACH HIV income countries strongly recommend systematic clinic in 2014. Our goal is to adhere to WHO LTBI screening in PLHIV and LTBI treatment for recommendations and perform LTBI screening those with a positive LTBI screening test.6,7 among all adult PLHIV, and to treat where appro- The notification rate of active TB disease in New priate. Zealand was 7.0 per 100 000 population in 2011.8 A recently published audit of HIV and TB in Auckland, METHODS New Zealand, identified 40 patients with HIV- associated active TB disease diagnosed between ACH is the tertiary referral centre for all PLHIV in the 1997 and 2009, representing 1.6% of all patients Auckland and Northland regions, serving an adult

Correspondence to: Nick Gow, Department of Medicine, , Taharoto Road, Auckland, New Zealand. e-mail: [email protected] Article submitted 16 February 2017. Final version accepted 29 May 2017. LTBI screening in Auckland, New Zealand 1009

Table 1 Patient characteristics (initial cohort)

Born/acquired HIV in high Born/acquired HIV in low All TB incidence country TB incidence country (n ¼ 752) (n ¼ 291) (n ¼ 461) n (%) n (%) n (%) Age, years, median 46 43 49 Female 139 (18) 106 (36) 30 (7) MSM mode of transmission 440 (59) 65 (22) 375 (81) CD4 count at presentation, cells/mm3, median 343 290 376 Receiving antiretroviral therapy 644 (86) 245 (84) 399 (87) HIV viral load , 1.3 log copies/ml 496 (66) 190 (65) 281 (61) First seen in clinic: 1990–2005 390 (52) 151 (51) 239 (52) 2006–2011 362 (48) 140 (48) 222 (48)

HIV ¼ human immunodeficiency virus; TB ¼ tuberculosis; MSM ¼ men who have sex with men. population of approximately 1.1 million.11 This excluded, leaving 752 for analysis. The most common study analysed two study cohorts: the initial cohort modes of transmission of HIV infection were via men consisted of all adult PLHIV attending the ACH HIV who had sex with men (MSM) (n ¼ 439), heterosex- clinic in 2011 who had been seen at two or more ual (n ¼ 244), injecting drug use (IDU) (n ¼ 10), IDU clinic visits; the second cohort was made up of all or MSM (n¼8), blood transfusion (n¼3), needlestick adult PLHIV newly attending the ACH HIV clinic in injury (n ¼ 1), and perinatal (n ¼ 1), and was 2014 who had been seen at two or more clinic visits. unknown in 46. Self-reported ethnicity was as The clinical records of all eligible adult PLHIV follows: NZ European (n ¼ 358), African (n ¼ 146), were reviewed. In the initial cohort, we established NZ Maori (n ¼ 59), South-East Asian (n ¼ 53), demographic information, LTBI screening test results European (n ¼ 49), Pacific Islander (n ¼ 32), East/ before July 2012, LTBI treatment and clinical South Asian (n ¼ 25), Australian (n ¼ 11), North outcomes. TST was performed by injecting 5 tuber- American (n ¼ 9), South American (n ¼ 5), other (n ¼ culin units (0.1 ml) of purified protein derivative 3), and not stated (n ¼ 2). Additional patient intradermally into the flexor surface of the upper characteristics are shown in Table 1. Four hundred forearm, with reading performed after 72 h. A and sixteen (55%) patients underwent LTBI screening positive TST was defined as a skin reaction of 75 on at least one occasion, with a median duration of 44 mm diameter. The ACH Laboratory reports QFN months after the first screening test until July 2012. A results as positive (70.45 international units [IU]/ml positive LTBI screen was found in 74 (10%): 44 with TB-Nil), negative (60.25 IU/ml TB-Nil), equivocal QFN, and 30 with the TST (Figure A). (0.25–0.45 IU/mL TB-Nil, where due to the inherent assay variability the qualitative interpretation of the High tuberculosis incidence subset assay may change on repeat testing) or indeterminate. In the initial cohort, 291 (39%) adult PLHIV had We defined a country with high TB incidence as .20/ been born in or acquired HIV infection in a high TB 100 000 cases/year.12 The extent of LTBI screening incidence country. Two hundred and thirty-eight was then re-assessed in the second cohort. (82%) underwent LTBI screening (Figure B) using The choice of LTBI treatment was at the discretion QFN (n ¼ 135), TST (n ¼ 90) or QFN and TST (n ¼ of the treating physician. LTBI treatment was 13). A positive screen was found in 55 patients (i.e., considered complete if at least 6 months of isoniazid 23% of those screened, or 19% of the total), 29 with (INH) or 4 months of rifampicin (RMP) was given. the TST and 26 with QFN. The median induration of Two-tailed Fisher’s exact test was used to analyse the TSTwas 14.5 mm in the 24 patients for whom this categorical data. result was recorded. Of the 13 patients screened using Institutional ethics approval was granted by the both TST and QFN, 7 had concordant negative Auckland City Hospital Research Office, Auckland, results, 2 had concordant positive results, and 4 had New Zealand, in 2012. discordant results, with 2 initially TST-positive and 2 initially QFN-positive. Of the 55 patients who screened positive, 44 RESULTS underwent LTBI treatment; 1 refused treatment, 1 Initial cohort died before commencing treatment, and in 3 cases After exclusion of six patients seen at the clinic only treatment was deferred due to inconsistent LTBI once, 789 adult PLHIV were under regular review. screening results; the remaining 6 patients, 5 with The median duration of clinic attendance until July positive TST results and 1 with a positive QFN result, 2012 was 81 months (range 7–255). Thirty-seven had did not receive LTBI treatment. In each case, this a previous diagnosis of active TB disease and were appeared to be because the result of their LTBI screen 1010 The International Journal of Tuberculosis and Lung Disease

Figure Number and percentage of patients undergoing LTBI screening and LTBI treatment in the initial and follow-up cohorts. A) Initial cohort (all, n ¼ 752); B) initial cohort (high TB incidence country, n¼291); C) initial cohort (low TB incidence country, n¼461); D) follow-up cohort (all, n¼ 73). LTBI ¼ latent tuberculous infection. was missed; the five missed TST results occurred treatment was started. The other patient underwent a before electronic reporting of laboratory results in second QFN test, as the patient’s HIV clinician was 2003, and the missed QFN result was only visible in a unaware of the first test result (this was only available separate encoded electronic reporting system. Five of in a separate encoded electronic reporting system); these six patients developed active TB disease there was no obvious TB exposure and LTBI between 2002 and 2008, with a range of 60–104 treatment was deferred due to the presence of months between positive TST and diagnosis of active peripheral neuropathy. The single positive TST had TB disease. All five were treated and cured; there an induration of 9 mm. The two patients screened were no deaths or complications arising from this using both TST and QFN had concordant negative treatment. The sixth patient was lost to follow-up results. There was no statistically significant differ- before he could be offered LTBI treatment. There ence when comparing positive QFN with TST were no other incident cases of active TB in this screening results in this population (P ¼ 0.70). subset after a median 57 months of follow-up. Risk factors for LTBI other than HIV infection were smoking (n ¼ 10), travel to a country with high Low tuberculosis incidence subset TB incidence (n ¼ 3), diabetes (n ¼ 2), IDU (n ¼ 2), In the initial cohort, of the 461 (61%) patients who contact with a case of known active TB disease (n¼2) had been born in or acquired HIV infection in a low and occupation as a health care worker (n ¼ 2). TB incidence country, 178 (39%) underwent LTBI Twelve patients (63%) had at least one other risk screening (Figure C) using QFN (n ¼ 159), TST (n ¼ factor, and six had 72 other risk factors. 17) or QFN and TST (n ¼ 2). A positive screen was Thirteen patients received LTBI treatment. Of the found in 19 patients (i.e., 11% of those screened, or remaining 6, treatment was deferred in 3 patients for 4% of the total): 18 with QFN and 1 with the TST. It unstated reasons, 1 patient refused treatment, 1 died is to be noted that two initially negative QFN results before the planned treatment initiation (cause of were positive on repeat testing within 2 years. One of death unknown), and in 1 patient no documented these patients had no obvious reason for the repeat consideration was given to LTBI treatment; this QFN test and there was no documented TB exposure appeared to be because of a missing TST result (the between the two tests; LTBI treatment was planned test was performed before electronic reporting of but the patient died (cause of death unknown) before laboratory results in 2003). None of these six patients LTBI screening in Auckland, New Zealand 1011

Table 2 Prevalence of LTBI screening among people living with HIV infection in low TB incidence, resource-rich settings

LTBI screen performed Overall LTBI prevalence LTBI prevalence by risk group by each screening test by risk group TB burden/ Sample CD4 Proportion Country 100 000/ size cells/mm3 on ART Low-risk High-risk TST QFN T-SPOT Low-risk High-risk of study year Year n median % % % % % % % % Canada13 5.2 2009 2 123 272 26 15 40 14.7 4.3 22.7 Switzerland14 6.3 2007 6 160 326 34 69 71 9.4 — — Australia15 6.4 2014 917 490 64 28 37 3.2 2.0 5.3 (born in Australia) (born overseas) Denmark16 7.1 2006 590 523 76 — — 4.6 1.6 10.2 Austria17 7.8 2009 830 194 60 NA (prospective) 4.5 3.8 17.4* Norway18 8.1 2014 298 427 67 NA (prospective) 24 26 25 7.2* 33* UK19 12 2013 520 458 67 NA (prospective) 3.0 14.3

* Active TB not excluded. LTBI ¼ latent tuberculous infection; HIV ¼ human immunodeficiency virus; TB ¼ tuberculosis; ART ¼ antiretroviral therapy; TST ¼ tuberculin skin test; QFN ¼ QuantiFERONW-TB Gold; T-SPOT ¼ T-SPOT.TB;NA¼ not applicable. was diagnosed with active TB disease after a median only 29% of patients had a retrospectively available of 37 months of follow-up. LTBI screening test result.9 Eighty-two per cent of the initial cohort who were born or acquired HIV Latent tuberculous infection treatment infection in a country with a high TB incidence were Of the 57 PLHIV in the initial cohort who underwent screened. Our LTBI screening rates from 2011 are LTBI treatment, 55 (96%) completed treatment: 40 similar to reported rates from resource-rich settings completed 9 months and 1 completed 8 months of (Table 2), which showed screening rates of 15–69% INH, 10 completed 6 months of INH, 3 completed 4 in ‘low-risk’ and 40–71% in ‘high-risk’ PLHIV months of RMP and INH and 1 completed 4 months populations. of RMP after developing a rash with INH after 2 An important finding of the current study was the months. A 57-year-old NZ European stopped INH at high proportion of positive LTBI screening results in 2 months due to severe malaise and moderately the ‘low-risk’ subset of the initial cohort. Our rate of elevated liver enzymes. A 61-year-old NZ European 11% in this subset was higher than the 1.6–7.2% stopped INH at 5 months due to moderately elevated positive LTBI screening results reported in the six liver enzymes. Side effects that did not require a studies where LTBI rates were calculated for similar change or cessation in treatment were documented in ‘low-risk’ cohorts (Table 2). These studies were 3 patients—2 with mildly elevated liver enzymes and conducted in countries with TB incidence rates 1 with severe nausea. similar to those in New Zealand, and included PLHIV with similar levels of immune suppression Second cohort and antiretroviral therapy coverage. There are several In the second cohort, 81 adult PLHIV attended the possible explanations for this discrepancy. First, two ACH HIV clinic for the first time in 2014. Three had of these studies may have underdiagnosed LTBI in newly or previously diagnosed active TB disease, one their low-risk cohorts,13,15 as evidenced by the low had previously undergone LTBI screening, and 4 died rates of LTBI screening performed. Second, our before undergoing full screening blood tests. Of the higher LTBI rate may have been due to false-positive remaining 73, 68 (93%) underwent LTBI screening results. Third, there may have been a degree of with QFN (Figure D). A positive LTBI screen was selection bias in our ‘low-risk’ cohort due to the HIV found in two patients: one of these completed LTBI clinician responsible deciding to screen PLHIV for treatment and the other declined treatment. Compar- LTBI based on risk factors that were not obvious at ing the initial cohort with the second cohort, there the time of the retrospective medical record review. was a statistically significant increase in LTBI We note that one study defined their ‘high-risk’ group screening (55% vs. 93%, P , 0.0001). according to place of birth,16 exposure to TB and IDU; in addition, multiple other risk factors have been identified that increase the risk of LTBI in DISCUSSION PLHIV, including ingestion of .50 g alcohol/day LTBI screening was incomplete in our 2011 cohort, (hazard ratio [HR] 1.2), ingestion of .100 g alcohol/ with only 55% of all adult PLHIV having document- day (HR 1.5), smoking (HR 1.4), health care work ed QFN or TST results. We postulate that this low (HR 1.94), illicit drug use (odds ratio [OR] 9.8), rate is due to a perceived low probability of LTBI in homelessness (OR 5.2), and incarceration (incidence PLHIV without a clear epidemiological risk. These rate ratio 26.2).20 data are in agreement with our recent analysis of The LTBI treatment completion rate (96%) in our active TB disease in adult PLHIV in Auckland, where cohort compares favourably with other studies from 1012 The International Journal of Tuberculosis and Lung Disease

Canada, Switzerland, England and Spain, where 3 World Health Organization. Guidelines for intensified between 37% and 95% of PLHIV who were treated tuberculosis case finding and isoniazid preventive therapy for 9,13,14,21 people living with HIV. Geneva, Switzerland: WHO, 2011. for LTBI completed treatment. 4 World Health Organization. WHO policy on collaborative TB/ Additional opportunities for quality improvement HIV activities: guidelines for national programmes and other were identified as a result of this study. Seven PLHIV stakeholders. WHO/HTM/TB/2012.1. WHO/HIV/2012.1 did not receive LTBI treatment because the result of Geneva, Switzerland: WHO, 2012. 5 Akolo C, Adetifa I, Shepperd S, Volmink J. Treatment of latent their LTBI screen was missed; five of these patients tuberculosis infection in HIV infected persons. Cochrane subsequently developed active TB disease. This Database Syst Rev 2010; (1): CD000171. represents a significant systems failure; we expect 6 Getahun H, Matteelli A, Abubakar I, et al. Management of that the risk of missing a positive LTBI screening latent Mycobacterium tuberculosis infection: WHO guidelines result has decreased significantly due to the introduc- for low tuberculosis burden countries. Eur Respir J 2015; 46: 1563–1576. tion of the more readily visible electronic laboratory 7 World Health Organization. Guidelines on the management of reporting of the QFN test, and the introduction of an latent tuberculosis infection. WHO/HTM/TB/2015.01. HIV database. We have advised our HIV clinicians of Geneva, Switzerland: WHO, 2015. those patients with positive LTBI screening test results 8 Institute of Environmental Science and Research Ltd (ESR). Tuberculosis in New Zealand: Annual Report 2011. Porirua, who have not received treatment, to ensure that those New Zealand: ESR, 2012. with missed results or previously deferred treatment 9 Luey C, Milne D, Briggs S, Thomas M, Handy R, Nisbet M. plans are considered for treatment. Similar missed HIV-associated tuberculosis in Auckland. NZMJ 2015; 128: opportunities have been reported elsewhere: in one 36–43. 10 Ministry of Health. Guidelines for tuberculosis control in New study of PLHIV, 246/390 TST-positive patients did Zealand, 2010. Wellington, New Zealand: Ministry of Health, not receive LTBI treatment, 16 (7%) of whom 2010. subsequently developed active TB disease.14 11 Statistics New Zealand. 2006 Census. Wellington, New We note that the high conversion rate from LTBI to Zealand: Statistics NZ, 2006. 12 World Health Organization. Global tuberculosis report, 2015. active TB that occurred in the high TB incidence WHO/HTM/TB/2015.22. Geneva, Switzerland: WHO, 2015. subset in the absence of LTBI treatment did not occur http://www.who.int/tb/publications/global_report/en/ Accessed in the low TB incidence subset; this may be due to the May 2017. shorter duration of follow-up from initial LTBI 13 Brassard P, Hottes T, Lalonde R, et al. Tuberculosis screening screening until the end of the study (37 vs. 57 and active tuberculosis among HIV-infected persons in a Canadian tertiary care centre. Can J Infect Dis Med Microbiol months) and/or the possibility of false-positive QFN 2009; 20: 51–57. results in the low TB incidence subset. 14 Elzi L, Schlegel M, Weber R et al. Reducing tuberculosis Screening for LTBI in PLHIV in Auckland was incidence by tuberculin skin testing, preventive treatment, and incomplete in our initial cohort, but comparable with antiretroviral therapy in an area of low tuberculosis transmission. Clin Infect Dis 2007; 44: 94–102 other low TB incidence countries. Screening signifi- 15 Doyle J S, Bissessor M, Denholm J T, et al. Latent tuberculosis cantly improved in our second cohort, although we screening using interferon-gamma release assays in an note the heterogeneity of the two cohorts. We suggest Australian HIV-infected cohort: is routine testing worthwhile? that the WHO recommendation for universal LTBI J Acquir Immune Defic Syndr 2014. 66: 48–54. 16 Brock I, Ruhwald M, Lundgren B, et al. Latent tuberculosis in screening in adult PLHIV should be followed in our HIV-positive, diagnosed by the M. tuberculosis-specific setting. interferon-gamma test. Respir Res 2006; 7: 56. 17 Aichelburg M C, Rieger A, Breitenecker F, et al. Detection and Acknowledgements prediction of active tuberculosis disease by a whole-blood The authors thank C Pikholz of the Auckland Regional Public interferon-gamma release assay in HIV-1-infected individuals. Clin Infect Dis 2009; 48: 954–962. Health Service, Auckland, for her assistance in developing the study 18 Pullar N D, Steinum H, Tonby K, et al. Low prevalence of protocol, and Associate Professor N Dickson, Preventive & Social positive interferon-gamma tests in HIV-positive long-term Medicine, Dunedin School of Medicine, Dunedin, New Zealand, immigrants in Norway. Int J Tuberc Lung Dis 2014; 18: 180– for his assistance in determining the mode of HIV acquisition. 187. Conflicts of interest: none declared. 19 Kall M, Coyne K, Garrett N, et al. Latent and subclinical tuberculosis in HIV infected patients: a cross-sectional study. References BMC Infect Dis 2012; 12: 107. 20 Pollock K, Tam H, Grass L, et al. Comparison of screening 1 World Health Organization. Tuberculosis and HIV. Geneva, strategies to improve the diagnosis of latent tuberculosis Switzerland: WHO, 2014. infection in the HIV-positive population: a cohort study. BMJ 2 Mack U, Migliori G B, Sester M, et al. & TBNET. LTBI: latent Open 2012; 2: e000762. tuberculosis infection or lasting immune responses to M. 21 Diaz A, Diez M, Bleda M J, et al. Eligibility for and outcome of tuberculosis? A TBNET consensus statement. Eur Respir J treatment of latent tuberculosis infection in a cohort of HIV- 2009; 33: 956–973 infected people in Spain. BMC Infect Dis 2010; 10: 261–269. LTBI screening in Auckland, New Zealand i

RESUME

CONTEXTE : La Nouvelle Z´elande, qui a une faible incidenceelev´ ´ ee ou y ayant acquis le VIH) et des patients incidence de tuberculose (TB), a historiquement adopt´e a` faible risque en recouranta ` des m´ethodes descriptives une approche bas´ee sur le risque vis-`a-vis du d´epistage de statistiques. l’infection tuberculeuse latente (LTBI) pour les RE´ SULTATS : Sur les 752 patients de la cohorte initiale, personnes adultes vivant avec une infection au virus de 416 (55%) avaient des documents relatifsaund´ ` epistage l’immunod´eficience humaine (PVVIH). de LTBI qui aet´ ´ e positif chez 74 (10%) d’entre eux, OBJECTIF : Evaluer le d´epistage de la LTBI, son notamment, 19/461 (4%) patientsa ` faible risque et 55/ traitement et les r´esultats dans notre population de 291 (19%) patientsa ` risqueelev´ ´ e. Le traitement de la PVVIH adultes. LTBI aet´ ´ e administr´e`a 13 patientsa ` faible risque eta44 ` SCHE´ MA : Uneetude ´ r´etrospective de revue des dossiers patientsa ` risqueelev´ ´ e. Sur 73 patients de la deuxi`eme cliniques d’une cohorte initiale de PVVIH adultes suivis cohorte, 68 (93%) ontet´ ´ ed´epist´es. au dispensaire VIH de l’hopital ˆ d’Auckland en 2011, et CONCLUSION : Le d´epistage de la LTBI aet´ ´ e incomplet une deuxi`eme cohorte de PVVIH adultes suivis dans notre centre mais s’est am´elior´e de 2011a ` 2014. Un r´ecemment dans ce service en 2014. Nous avons nombre significatif de patients atteints de LTBI ne analys´e des patientsa ` risqueelev´ ´ e(n´es dans un paysa ` venaient pas d’un paysa ` incidenceelev´ ´ ee de TB.

RESUMEN

MARCO DE REFERENCIA: En Nueva Zelanda la un pa´ıs con alta incidencia de TB o que contrajeron all´ı incidencia de tuberculosis (TB) es baja y en los adultos la infeccion ´ por el VIH) y pacientes con bajo riesgo. que presentan infeccion ´ por el virus de la RESULTADOS: De los 752 pacientes de la cohorte inmunodeficiencia humana (PVVIH) tradicionalmente inicial, en 416 se pudo documentar la deteccion ´ se ha aplicado una estrategia de deteccion ´ sistema´tica de sistema´ticadelaLTBI(55%)yelresultadofue la infeccion ´ tuberculosa latente (LTBI) en funcion ´ de los positivo en 74 casos (10%), a saber: 19/461 (4%) riesgos. pacientes de bajo riesgo y 55/291 (19%) pacientes de OBJETIVO: Evaluar la deteccion ´ sistema´tica de la LTBI, alto riesgo. Recibieron tratamiento por LTBI 13 de los su tratamiento y los desenlaces terap´euticos en la pacientes de bajo riesgo y 44 pacientes de alto riesgo. En poblacion ´ adulta PVVIH. la segunda cohorte, se practico ´ la deteccion ´ sistema´tica ME´ TODOS: Se llevo ´ a cabo el ana´lisis retrospectivo de en 68/73 (93%) pacientes. las historias cl´ınicas de una cohorte inicial de PVVIH CONCLUSIO´ N: La pra´ctica de la deteccion ´ sistema´tica atendidos en el consultorio del VIH del hospital de de la LTBI en este consultorio era incompleta, pero Auckland en el 2011 y una segunda cohorte de PVVIH mejoro ´ del 2011 al 2014. Una proporcion ´ considerable adultos que comenzaron a acudir a este consultorio en el de pacientes con diagnostico ´ de LTBI no proven´ıa de 2014. Mediante estad´ısticas descriptivas se analizaron pa´ıses con alta incidencia de TB. pacientes con alto riesgo de contraer la TB (nacidos en