Tuberculosis (TB) is a potentially fatal contagious disease that can affect almost any part of the body but is mainly an infection of the lungs. It is caused by micro-organisms of the Mycobacterium tuberculosis complex. It is the second greatest killer worldwide due to a single infectious agent, after the Human Immunodeficiency Virus (HIV). Without treatment, fatality is 50% in immune competent persons. TB remains the leading cause of death among HIV positive persons, causing one fifth of the deaths. The World Health Organization estimates that one third of the world population is infected by this micro-organism but only 5 to 10% develop TB disease. Nevertheless, this enormous reservoir leads to around 1.4 millions deaths annually. Standard curative treatment lasts at least 6 months and includes 4 different drugs. Toxicity of the drugs leading to (severe) adverse events and the long duration of the daily administration challenges patient’s compliance. Subinhibitory concentration of the drugs (due to poor adherence) can induce resistance of the mycobacteria to the provided drugs. Unlike most bacteria where resistance is acquired by plasmids, drug resistance of mycobacteria is obtained by genomic mutations. “Multi drug-resistant tuberculosis (MDR-TB)” is strictly defined as TB resistant to specifically isoniazid and rifampicin, the two main first line drugs. “Extensively drug resistance (XDR)” is defined as MDR-TB with additional resistance to any of the fluoroquinolones (such as ofloxacin or moxifloxacin) and to at least one of three injectable second-line drugs (amikacin, capreomycin or kanamycin). The increase of MDR-TB represents an enormous challenge to Public Health globally. This research examined different aspects of tuberculosis resistance performed in the Belgian National Reference Center, a clinical laboratory setting. <p><p>First of all, a profound analysis of the MDR-TB situation in Belgium was conducted. It is the first retrospective population-based survey of MDR-TB in Belgium, covering a 15-year period (1994-2008). It comprises 174 patients representing more than 80% of the culture positive MDR-TB patients reported to the Belgian register, thus this study is considered of national relevance. It includes bacteriological and molecular data on the isolates as well as clinical aspects of the patients and treatment results. Considering only the patient’s first MDR-TB isolate, an increase over time was observed in the number of isolates resistant to a second-line drug as well as the total number of drugs each isolate was resistant to. XDR-TB was detected since 2002 and panresistant TB (resistant to every available antituberculosis drug) since 2009. Overall, a successful treatment outcome was obtained for 67.8% of the MDR-TB cases. Drug susceptibility testing (DST) of Mycobacterium tuberculosis to first line drugs (isoniazid, rifampicin, ethambutol and pyrazinamide) in liquid culture medium has a turn around time of at least two weeks, after identification of the positive culture (obtained after 2 to 4 weeks) from the patient’s clinical isolate. In order to provide the clinician with valuable information about the isolated mycobacteria leading to patient adapted therapy before bacteriological DST results are available, resistance is predicted by detection of mutations in certain genes of the mycobacteria. It is common practice for rifampicin (rpoB gene) and isoniazid (katG gene and/or inhA promoter region). In this MDR-TB collection, rifampicin resistant related mutations were found in 97.1% (168/173) of the clinical isolates and isoniazid resistant related mutations in 94.1% (160/170). The pncA, embB and gyrA genes have been sequenced to identify possible mutations because of their possible involvement with resistance to pyrazinamide, ethambutol and the fluoroquinolones respectively. However, little is known about the resistance prediction value of the mutations in these genes.<p>The study is also the first study on the molecular epidemiology of MDR-TB in the country. DNA fingerprinting showed a large diversity of strains (67% of the patients were infected by a strain with a unique pattern) and further epidemiological examination revealed limited local transmission of MDR-TB in Belgium.<p><p>The second part investigated the pncA gene and its association with pyrazinamide resistance in MDR-TB isolates from Belgium and in vitro cultured spontaneous mutants. The genetic analysis showed that 98.3% (59/60) of the Belgian clinical MDR pyrazinamide resistant (PZAR) isolates present a mutation in the pncA gene. We found 1.7% (1/60) of the PZAR MDR-isolates encoding wild type pncA and flank. A total (PZAR and PZAS) of 41 different amino acid changes, 3 protein truncations and 5 frameshifts were observed including eight novel mutations: 8Asp>Ala, 13Phe>Leu, 64Tyr>Ser, 107Glu>stop, 143Ala>Pro, 172Leu>Arg and frameshifts starting in codon 55 and 82. Analysis of all observed mutations (i.e. in clinical isolates as well as spontaneous mutants) revealed that they are not always associated with drug resistance and that they are not scattered randomly throughout the gene, but occur rather at preferential sites such as in codons with amino acids associated with either iron or substrate binding and catalytic active sites. The frequency of in vitro mutagenesis to pyrazinamide at pH 6.0 was determined and found to be relatively high at 10-5 CFU/ml.<p><p>Finally, the in vitro activity of tobramycin and clarithromycin (with unclear efficacy against M. tuberculosis) was evaluated on 25 M. tuberculosis clinical isolates with various resistance profiles. The effect of the drugs administered together was examined for possible synergistic effect. The median minimum inhibitory concentration (MIC) of 8 µg/ml obtained for both drugs in this study is rather high but are beyond the concentrations obtained in lung tissues. This suggests that both drugs should be investigated further as potential adjuncts to the treatment of resistant TB when other alternatives have failed; in particularly through new drug delivery systems such as the Dry Power Inhaler which allows local drug deposition with high drug concentrations in the lungs but low toxicity due to limited systemic absorption. In addition, for 36% of the tested isolates a decrease of the MIC of clarithromycin by a single or twofold dilution was observed in the presence of a subinhibitory concentration of tobramycin and no antagonistic effect was seen for the remaining isolates.<p><p>This research illustrates different (laboratory) aspects in the fight against drug resistant TB, all using the Belgian TB collection: characterisation of the Belgian MDR-TB situation on bacteriological, molecular and epidemiological level; profound analysis of genomic mutations and their possible association with drug resistance; and investigation of synergistic activity of drugs with low efficacy against M. tuberculosis.<p> / Doctorat en Sciences biomédicales et pharmaceutiques / info:eu-repo/semantics/nonPublished

Magister Curationis - MCur / Multidrug resistant TB (MDR-TB) is a form of TB caused by bacteria (germs) that are resistant to the usual drugs that are used to treat "normal" TB. The duration of treatment for MDR-TB is a maximum of 22 months. People with MDR-TB are treated in specialized tertiary hospitals and in out-patient clinics in the PHC facilities. The treatment includes a six months injectable phase with a wide range of TB drugs. The adverse effects of MDR-TB drugs are among the worst side effects ever reported by patients. The aim of the current study was to explore the experiences of adverse effects of MDR-TB treatment amongst patients in a primary health care facility in the Western Cape. An explorative qualitative study design was used to explore the experiences of patient with the adverse effects of MDR-TB treatment in a primary health care facility in the Western Cape. In depth interviews were conducted with 12 MDR-TB patients. Data analysis was done by using the Tesch's method of content analysis. The study revealed that participating MDR-TB patients experienced various emotional, financial, physical and social challenges. Participants explained that the experience of being on MDR-TB treatment is emotionally draining; the pain and discomfort of the adverse effect of treatment makes a person to feel anxious and depressed. Financially they depended on social grants because they had to stop working after starting treatment. They could not function well physically because of the toxic nature of the adverse effects of treatment; which resulted in fatigue, dizziness and burning sensation on the feet and hands. They were faced with a lot of stigma from the community and even family members because of their illness. The study also revealed that in spite of the challenges and obstacles the participants were all motivated to complete their treatment and get cured. It is recommended that more support structures be made available for patients who are being treated for MDRT-TB such as; psychotherapy, social support and counselling on health education. Provision needs to be made for patients who are receiving daily injection; for it to be given in their homes. Health care providers treating MDR-TB patients need to do home visits together with MDR-TB adherence counsellors, to monitor the physical wellbeing of patients at home. This will also provide patients with the platform to discuss their health concerns in a more accommodative and relaxed environment. New drug regimen with fewer tablets and less treatment duration is needed for MDR-TB.

Magister Artium (Development Studies) - MA(DVS) / This study is interested in understanding and describing the everyday reality of clinical researchers from the perspective of those who operate on the grassroots level –in this case, the field staff working under the guidance of the study coordinator and principal investigators.

Two of the primary occupational health threats to employees in the mining industry are noise-induced hearing loss (NIHL) and occupational lung diseases (OLD) with Tuberculosis (TB) included in the latter. The objective of this study was to investigate the hearing profile of a group of gold miners with and without TB to determine the effect of TB and its associated risk profile on hearing. Workers in AngloGold Ashanti mine in South Africa were recruited due to the fact that they present with these two health threats namely NIHL and TB. The audiological and medical surveillance data of 2698 subjects (between the years 2001 and 2009) were used in analyses. Hearing thresholds for the air conduction frequencies (0.5, 1, 2, 3, 4, 6, 8 KHz) in both ears were analysed in conjunction with biographic and occupational data. Subjects were divided into three groups, two experimental groups (Single TB treatment, n= 911 and Multiple TB treatment, n= 376) and one control group (n= 1411). A highly significant difference (p<0.01) was noted between the control group and both TB treatment groups across most frequencies and hearing parameters analysed, although the higher frequencies were more affected. Pair wise comparisons revealed the largest differences in hearing thresholds throughout between the control group and the multiple TB treatment groups. The smallest differences in hearing thresholds were evident between the two TB groups with the multiple TB treatment group presenting with the poorest thresholds. TB and its related risk profile had a pronounced influence on the decline of hearing thresholds. Thresholds for the multiple TB treatment group indicated more deterioration than the hearing thresholds of the single TB treatment group. This may point to the possibility that the influence of repeated TB on the subjects’ hearing thresholds over time was more pronounced than a single incidence of TB. It is still necessary however to separate the effects of the disease from the effects of the treatment on hearing. / Dissertation (MCommunication Pathology)--University of Pretoria, 2012. / Speech-Language Pathology and Audiology / Unrestricted

Magister Pharmaceuticae - MPharm / Tuberculosis and mv Tuberculosis (TB) is a major contributor to the disease burden in developing countries resulting in the deaths of approximately 2 million people a year. South Africa (SA) has one ( of the highest annual TB incidences with an estimate of 558 per 100 000 population (2003) and the situation shows no sign of abating. TB remains the most common opportunistic infection and cause of death amongst HIV- infected patients. Both TB and HIV treatment depends exclusively on multi-drug regimens that require close monitoring among health care professionals. With increasing workload due to staff shortage and high patient load, the quality of care in nurse-led primary care clinics may be compromised. Existing clinic staff may overlook drug-drug interactions, side effects and may not be aware of the consequences when a formulation is modified during multi-drug therapy administration. As the custodian of medicines, pharmacists are ideally placed to monitor therapy. Clinic-based training programs that are offered to nurses provide an opportunity to work alongside clinic staff and engage in patient-centered care where the pharmacotherapeutic the outcome of TB and HIV drug regimens could be closely monitored. XVll Aims The primary and secondary aims of the study were to: • Assess current practice patterns of TBIHIV at primary healthcare clinics in the Western Cape, • Assess the need for a clinic-based TBIHIV training among final year pharmacy students in UWC. http://uwc.ac.za Objectives To achieve the primary aim the researcher; 1. Conducted a baseline study at Ravensmead Community Health Centre(CHC) to assess current TBIHIV practice among HCP's and co-infected patients, 2. Assessed current practice patterns at Delft South ARV clinic and Elsies River TB clinic (pre-intervention), 3. Designed and implemented a clinic-based TBIHIV intervention tool for potential use by pharmacists at Delft South and Elsies River clinics (intervention phase), 4. Evaluated patient receptivity of the intervention tool amongst patients at Delft South and Elsies River clinics (post-intervention phase). XVlll To achieve the secondary aim the researcher; 5. Introduced a clinic-based training for seven final year pharmacy students, 6. Designed and administered an assessment to both control and experimental students, 7. Assessed scores between students who received the training (experimental group) with those who did not receive the training (control group). Results and discussion Findings from the baseline study indicate the need for the involvement of a trained pharmacist in TB and HIV management. Even though three-quarters (77.8%; 14) of the patients preferred receiving their TB information from the clinic nurse, almost two-thirds (63.2%; 12) of the patients believed that pharmacists assisted with their treatment provision. Patient data obtained from the clinic record card showed that almost two-thirds of the patients reported that they had experienced side effects (64.4%); the therapy of more than one-quarter (26.4%) showed drug-drug interactions and onset of adverse effects (1.1 %). Post-intervention, the data showed that patients' viewed the pharmacist's role more positively. Almost all responses (97.5%; 39) favored the services of a pharmacist in the clinic. In conclusion, findings from the post-intervention patient study underpin that a clinic-based role for the pharmacist is imminent. All seven (100%) of the experimental students passed the assessment and had scores in the range between 26 and 45 and more than three-quarters (78.4 %; 29) of the control students passed with marks within this range. Conclusion A trained pharmacist would be competent to work alongside nursing staff in optimizing care provision in the clinical management of TB and HIV in patients. The existing clinic-based TB/HIV program could be supplemented with theoretical concepts in the final year of undergraduate pharmacy training.

Thesis (MSc. (Microbiology)) -- University of Limpopo, 2019 / The emergence of drug resistance to the first line drugs complicates the treatment of tuberculosis (TB), especially in parts of sub-Saharan Africa where accessibility to quality health care is limited. The search for alternative medication has been the centre of research for years due to challenges posed by infectious organisms including drug resistance, lengthy treatment periods and lack of quality health care in developing countries. Stomatostemma monteiroae is used in traditional medicine to treat TB and related symptoms. The aim of this study was to isolate and characterise compounds with antimycobacterial activity from Stomatostemma monteiroae. The plant materials were collected from Ga-Madiga village in Limpopo province of South Africa. Different plant parts namely: leaves, twigs, roots, tuber and tuber-peels were separated, washed, dried and milled to a fine powder. Several solvents (n-hexane, dichloromethane, acetone and methanol) were used to extract the plant material using various extraction methods such as maceration, defatting, and extract enrichment procedure and phytochemical analysis was done using standard chemical tests and thin layer chromatography. The qualitative antioxidant activity was determined by the thin layer chromatography (TLC) based 2,2-diphenyl-1picrylhydrazyl (DPPH) free radical scavenging activity and quantitative antioxidant activity was determined using colorimetric DPPH free radical scavenging and ferric reducing power assay. Antimycobacterial activity of the extracts was assessed using bioautography and micro dilution method tested on Mycobacterium smegmatis (ATCC 1441), Mycobacterium tuberculosis (ATCC 25177) and M. tuberculosis H37Rv (ATCC 27294). The cytotoxic effects of the extracts were evaluated using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay on Vero monkey kidney cells. The compounds with antimycobacterial activity were isolated using bioassay-guided fractionation and purified using preparative thin layer chromatography and thereafter identified using NMR spectroscopy to elucidate the structure. Various phytochemical constituents were detected in different plant parts, with the leaves and twigs possessing more of the phytoconstituents analysed. The TLC profile of S. monteiroae indicated that more compounds are non-polar to intermediate in polarity. The antioxidant activity analysis on TLC plates indicated that all the plant parts have low antioxidant activity, this was also confirmed by xxii quantitative tests. The leaves of S. monteiroae had antimycobacterial activity when analysed using bioautography, while other plant parts had no active bands. The minimum inhibitory concentration values were much higher than the positive control rifampicin and the roots (0.31 mg/mL) followed by the leaves (0.83 mg/mL) had lower inhibitory concentrations when tested against M. smegmatis. The MIC values of extracts against TB causing strains varied greatly, the leaves and the roots had even higher MIC value. Toxicity analysis indicated that all plant parts were non-toxic towards Vero cells (LC50 > 0.02 mg/mL). Bioassay-guided fractionation enabled isolation of one antimycobacterial pure compound from the leaves extracts. The isolated compound was identified using NMR and was found to be a sitosterol derivative 8,9-dehydro-4-methyl-24-vinylobtusifoliol. This compound had a noteworthy activity against M. smegmatis. The present study validates the use of S. monteiroae in the treatment of TB related symptoms traditionally. Further studies are required to analyse the cytotoxic effects of the isolated compound and also testing the antimycobacterial activity of the isolated compound on TB causing pathogens. / National Research Foundation (NRF)

Mycolic acids are long chain lipids from the cell walls of Mycobacterium tuberculosis. The Nkuku phage display library was previously used to obtain monoclonal antibody binders to mycolic acids. In total 11 binders were obtained of which one was selected (MAC10) for further investigation by genetic engineering as presented in this dissertation. The antibodies of the Nkuku phage display library are in the format of single chain variable fragments (scFv). ScFv’s constitute only the epitope binding domains of an antibody consisting of the VH and VL domains fused into a single chain by a flexible linker protein. The selected anti-mycolic acid scFv is referred to as mycolic acid clone 10 (MAC10). Genes encoding the scFv’s of the Nkuku phage display library were cloned into the plasmid pHEN-1, a phage display vector. This vector is not commercially available or ideally suited for expression of scFv proteins. Therefore two vectors were investigated as possible targets for subcloning. The plasmids pGE20 and pAK400 were previously used for the expression of scFv antibody proteins. Subcloning into plasmid pAK400 proved to be the more efficient of the two investigated for subcloning. This subcloning yielded the recombinant plasmid pAKJS. Following the subcloning scFv protein expression was attempted using the plasmids pMAC10 (derived from pHEN-1) and pAKJS (derived from pAK400). Expression of MAC10 using plasmid pMAC10 in both Escherichia coli TG-1 and HB2151 was constitutive. This demonstrates that plasmid pHEN-1 is a non ideal vector as expression should not occur unless induced. Expression of MAC10 did not occur when pAKJS and Escherichia coli HB2151 were used. This was due to both the vector and expression host producing inhibitor protein for the Lac Z promoter controlling expression of the scFv. The MAC10 gene was subsequently randomized using the directed evolution method, error prone PCR. Sequence analysis of the five selected mutants indicated an average mutation rate of 8.6 mutations per 1000 base pairs. From the combined total of all five mutants, transversions made up the majority of substitutions. The majority of transversion mutations occurred at A-T base pairs. Transition substation mutations that made up the minority of total mutations occurred mostly at G-C base pairs. / Dissertation (MSc)--University of Pretoria, 2012. / Biochemistry / unrestricted

Background: Disabling hearing loss is a global burden. This burden is worsened by the emergence of multi-drug resistant tuberculosis (MDR-TB). Some of the medications used to treat MDR-TB are damaging to the cochlea and auditory nerve (ototoxic) and can lead to permanent hearing loss and/or balance disorders. Ototoxicity monitoring aims to reduce this burden by preventing or minimising the damage caused by ototoxic treatment as it can progress and worsen speech perception difficulties. However, the proposed test battery for ototoxicity monitoring is lengthy and demands active participation which is not ideal for ill patients (such as those on MDR-TB treatment). The Sensitive Range of Ototoxicity (SRO) technique is recommended to shorten the test time. The SRO consists of seven consecutive relatively high frequencies determined from the highest frequency the participant responded to. The SRO technique is time efficient. Although the SRO technique provides the prospect of a shortened test battery, there is still a global lack of audiologists. Automated audiometry is a vital application for testing especially when audiologists are not available to physically do the test. Automated audiometry has been previously validated. Clinically, automated audiometry is objective and allows for standardisation. Even though automated audiometry helps improve access to monitoring more patients, patient preference is an important factor when using automated audiometry to ensure patient-centred care is not compromised. Aims and Objectives: This study aimed to investigate the specificity and sensitivity of the SRO technique with automated audiometry compared to the gold standard (manual audiometry). This comparison was made by firstly, determining the testing time efficiency and the correlation of thresholds obtained with the different test methods and, secondly, testing the diagnostic value of automated audiometry using the SRO technique. The incidence of an ototoxicity-induced hearing loss was described by determining the time interval between starting ototoxic MDR-TB treatment and the onset of a significant threshold shift (STS) according to ASHA's criteria. Lastly, the test method preference of the participants with MDR-TB was described and compared using a short exit survey. Study Design: A prospective repeated-measures study design was used. Participants were chosen based on a risk factor (i.e. exposure to ototoxic medication) for an outcome of interest (i.e. the presence or absence of an STS). With a repeated measures study, multiple tests using different test methods can be compared with the same sample. Participants: Twenty-seven in-patients at Brooklyn Chest Hospital and DP Marais TB Hospital with normal hearing and on MDR-TB medication were included in the study. Their age range was from 19 to 51 years old with an average age of 33 years old. Non-probability convenience sampling was used as it was cost-effective, reduced data collection time and was relatively easy to execute. Data collection materials and procedures: The procedure for data collection included weekly follow-up testing for a maximum of four weeks. The test battery was as follows: an auditory symptom questionnaire, otoscopy examination, and manual and automated audiometry using the SRO technique with a fifteen-minute break in between. Participants were tested with the KUDUwave ™ in a non-sound treated room. The frequency range was determined with the SRO technique. If an STS was obtained, the patient was discharged from the study after completing an exit survey. Statistics: Analysis included descriptive statistics and inferential statistics. A Bonferroni corrected p-value (initially p ≤ 0.05) was used. Manual and automated audiometry thresholds were compared using the Pearson's Correlation Coefficient test. Manual and automated audiometry testing time and threshold means were compared using paired sample's t-tests. The diagnostic value of automated audiometry with the SRO technique was assessed with Receiver Operating Characteristics (ROC) Curves. Results: Manual audiometry was statistically more time-efficient compared to automated audiometry by an average of one minute and ten seconds (t (94) = -5.44; p< 0.003). There was a strong positive correlation for both left and right ears between the thresholds' obtained from manual and automated audiometry at 8kHz to 16 kHz (df> 28 = r > 0.70, p< 0.003). Automated audiometry was found to be a fair diagnostic test (area under the curve was 0.75; p= 0.002). Also, the ROC curve revealed that automated audiometry had a sensitivity of 61% and specificity of 90% when compared to manual audiometry (gold standard). Only participants that started data collection within 31 days after starting their MDR-TB treatment were included in the analysis of determining the incidence of an ototoxicity-induced hearing loss (n= 24 ears). This study found that 41.67% of ears (n= 10) had an ototoxicity-induced hearing loss. A box and whisker plot revealed that data was skewed to the right (i.e. more variation in data between the median and the maximum values) and that the median number of days for an ototoxicity-induced hearing loss to appear was 33 days. Secondly, 55.55% of participants (n=15 out of 27) reported auditory symptoms before data collection commencement. Aural fullness was the most reported symptom (n= eight out of 15). Ten out of 15 (66.66%) participants that reported auditory symptoms obtained an ototoxicity-induced hearing loss. Lastly, most participants (i.e. 13 out of 19; 68.42%) that completed the exit survey had no preference between manual or automated audiometry. The common rationale among these participants was “No difference noted.” Conclusion: This research study has revealed that manual audiometry was more time-efficient compared to automated audiometry in patients with MDR-TB. Also, automated audiometry was a fair diagnostic test. It may aid in reducing the disproportionate audiologist to patient ratio, especially in a developing country. However, manual audiometry (with the SRO technique) is more clinically appropriate in patients that are difficult-to-test. Secondly, audiometric settings can be changed to accommodate testing frequencies in 1/6 octaves so that the SRO technique can be clinically adopted. An ototoxicity-induced hearing loss seems to appear 33 days after ototoxic MDR-TB treatment commencement. Aural fullness was a commonly reported symptom among participants with MDRTB. Aural fullness is omnipresent in peripheral auditory pathologies. Therefore, auditory symptoms reported by patients' needs a comprehensive audiological investigation. Lastly, more research is needed on how patients (and clinicians) experience the advances in technology innovation especially in audiology where technology innovation is continuously evolving.

Coevolution between Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis, and the human host has been documented for thousands of years. Interestingly, while T cell immunity is crucial for host protection and survival, T cell antigens are the most conserved region of the Mtb genome. Hypothetically, Mtb adapts under immune pressure to exploit T cell responses for its benefit from inflammation and tissue destruction for ultimately transmission. EsxH, a gene encoding immunodominant TB10.4 protein, however, contains polymorphic regions corresponding to T cell epitopes. Here, I present two complementary analyses to examine how Mtb modulates TB10.4 for immune evasion. First, I use a naturally occurring esxH polymorphic clinical Mtb isolate, 667, to investigate how A10T amino acid exchange in TB10.4 affect T cell immunity. To verify and identify the cause of the immunological differences, I construct isogenic strains expressing EsxHA10T or EsxHWT. In combination with our recent finding that TB10.44-11-specific CD8 T cells do not recognize Mtb-infected macrophages, we hypothesize that TB10.4 is a decoy antigen as it distracts host immunity from inducing other potentially protective responses. I examine whether an elimination of TB10.44-11-specific CD8 T cell response leads to a better host protective immunity. The studies of in vivo infection and in vitro recognition in this dissertation aim to provide a better understanding of the counteraction between immune evasion and protective immunity.

Tuberculosis (TB) and human immunodeficiency virus (HIV) are difficult conditions to manage, in tandem they pose even more challenges to public health programs in identifying coinfection to ensure that all TB cases are treated to completion of therapy (COT). The purpose of this study was to test variables that predicted COT among the HIV/TB coinfected population of non-Hispanic, U.S.-born Blacks alive at the time of diagnosis. Social determinants of health were the theoretical foundation used to guide the study based on data from the Report of Verified Cases of TB (RVCT) between 2009 and 2014. Relationships were tested between ethnic/racial group membership and the likelihood of COT, and whether any association to COT was moderated by COT eligibility; a Centers for Disease Control and Prevention calculated algorithm considering disease severity, site, age, and disease complexity. The research design was a longitudinal quantitative approach using binary logistic regression to identify correlated variables associated with COT in the final model. The results showed no statistically significant differences among racial/ethnic groups, age, and gender for COT. COT was moderated by COT eligibility; odds ratio (5.4 - 11.6) times more likely to complete therapy. This study supports positive social change for programs by providing data driven outcomes to providers that support outreach, patient education, and disease prevention. In addition, this research describes an evaluation metric based on performance to set a foundation for collaboration among partners who manage other comorbidities in the United States.