Tuberculosis in Antiretroviral Treatment Programs in Lower Income Countries: Availability and Use of Diagnostics and Screening

Abstract

ObjectivesIn resource-constrained settings, tuberculosis (TB) is a common opportunistic infection and cause of death in HIV-infected persons. TB may be present at the start of antiretroviral therapy (ART), but it is often under-diagnosed. We describe approaches to TB diagnosis and screening of TB in ART programs in low- and middle-income countries.Methods and findingsWe surveyed ART programs treating HIV-infected adults in sub-Saharan Africa, Asia and Latin America in 2012 using online questionnaires to collect program-level and patient-level data. Forty-seven sites from 26 countries participated. Patient-level data were collected on 987 adult TB patients from 40 sites (median age 34.7 years; 54% female). Sputum smear microscopy and chest radiograph were available in 47 (100%) sites, TB culture in 44 (94%), and Xpert MTB/RIF in 23 (49%). Xpert MTB/RIF was rarely available in Central Africa and South America. In sites with access to these diagnostics, microscopy was used in 745 (76%) patients diagnosed with TB, culture in 220 (24%), and chest X-ray in 688 (70%) patients. When free of charge culture was done in 27% of patients, compared to 21% when there was a fee (p = 0.033). Corresponding percentages for Xpert MTB/RIF were 26% and 15% of patients (p = 0.001). Screening practices for active disease before starting ART included symptom screening (46 sites, 98%), chest X-ray (38, 81%), sputum microscopy (37, 79%), culture (16, 34%), and Xpert MTB/RIF (5, 11%).ConclusionsMycobacterial culture was infrequently used despite its availability at most sites, while Xpert MTB/RIF was not generally available. Use of available diagnostics was higher when offered free of charge.

Empirical tuberculosis therapy versus isoniazid in adult outpatients with advanced HIV initiating antiretroviral therapy (REMEMBER): a multicountry open-label randomised controlled trial

“…Likewise, patients with advanced HIV may have minimal changes on chest radiography. The GeneXpert MTB/RIF assay (Xpert MTB/RIF), has improved sensitivity in sputum 9 but availability of this test remains limited 10 and implementation of Xpert MTB/RIF alone has not decreased HIV and TB-associated mortality 11–13 . Limitations of existing diagnostics contribute to major ongoing challenges in diagnosing and treating HIV-associated TB in resource-limited settings.…”

Detection and management of drug-resistant tuberculosis in HIV-infected patients in lower-income countries

“…The International epidemiologic Databases to Evaluate AIDS (IeDEA) is a global network of ART programs (11, 16, 18). Participating programs routinely collect data on HIV-infected persons.…”

“…The survey project is described in details elsewhere (18). In brief, we surveyed ART programs treating HIV-infected adults in sub-Saharan Africa, Asia and Latin America between March 1 and July 1, 2012.…”

Tuberculosis in Pediatric Antiretroviral Therapy Programs in Low- and Middle-Income Countries: Diagnosis and Screening Practices

“…The overall survey project and the participating sites are described in detail elsewhere [18]. The first part of the survey collected data on program-level characteristics related to the management of childhood TB (availability of diagnostic tools, screening, and treatment practices).…”