Undiagnosed Tuberculosis Among HIV Clinic Attendees

Kufa, Tendesayi; Mngomezulu, Victor; Charalambous, Salome; Hanifa, Yasmeen; Fielding, Katherine; Grant, Alison D.; Wada, Nikolas; Chaisson, Richard E.; Churchyard, Gavin J.; Gounder, Celine R.

doi:10.1097/qai.0b013e318251ae0b

Cited by 35 publications

(19 citation statements)

References 19 publications

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“…The review included four studies conducted during the ART era and, though overall ART coverage was not included, TB prevalence in these four studies was equal to or greater than in studies conducted prior to ART rollout, suggesting that individuals are initiating ART too late or are not linked to treatment at all. Studies conducted in clinics in South Africa have previously highlighted the large burden of undiagnosed TB among the ambulatory HIV-positive population [30,31], but investigation for TB is largely based on reporting respiratory symptoms, using sputum-based diagnostic tests [32,33]. A recent study conducted in Cape Town found that, of 139 HIV-positive individuals diagnosed with TB during admission to hospital (median CD4 count 80 cells/μL; 35% on ART for a median 1.3 years), 115 (83%) had at least one non-respiratory sample that was positive on testing with Xpert® MTB/RIF, or culture positive for M .…”

Section: Discussionmentioning

confidence: 99%

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

et al. 2016

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BackgroundEarly mortality among HIV-positive adults starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis (TB) the leading cause of death. However, current methods to estimate TB-related deaths are inadequate and most autopsy studies do not adequately represent those attending primary health clinics (PHCs). This study aimed to determine the autopsy prevalence of TB and other infections in adults enrolled at South African PHCs in the context of a pragmatic trial of empiric TB treatment (“TB Fast Track”).Methods and FindingsAdults with CD4 ≤150 cells/μL, not on ART or TB treatment, were enrolled to TB Fast Track and followed up for at least six months. Minimally invasive autopsy (MIA) was conducted as soon as possible after death. Lungs, liver, and spleen were biopsied; blood, CSF, and urine aspirated; and bronchoalveolar lavage fluid obtained. Samples underwent mycobacterial, bacterial, and fungal culture; molecular testing (including Xpert® MTB/RIF); and histological examination. 34 MIAs were conducted: 18 (53%) decedents were female; median age was 39 (interquartile range 33–44) years; 25 (74%) deaths occurred in hospitals; median time from death to MIA was five (IQR 3–6) days. 16/34 (47%) had evidence of TB (14/16 [88%] with extrapulmonary disease; 6/16 [38%] not started on treatment antemortem); 23 (68%) had clinically important bacterial infections; four (12%) cryptococcal disease; three (9%) non-tuberculous mycobacterial disease; and two (6%) Pneumocystis pneumonia. Twenty decedents (59%) had evidence of two or more concurrent infections; 9/16 (56%) individuals with TB had evidence of bacterial disease and two (13%) cryptococcal disease.ConclusionsTB, followed by bacterial infections, were the leading findings at autopsy among adults with advanced HIV enrolled from primary care clinics. To reduce mortality, strategies are needed to identify and direct those at highest risk into a structured pathway that includes expedited investigation and/or treatment of TB and other infections.

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Section: Discussionmentioning

confidence: 99%

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

et al. 2016

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“…[1] Among persons on long-term ART, the prevalence of undiagnosed TB remains high, and underscores the need for ongoing TB screening. [7,8] TB screening should be scaled up to achieve high coverage to ensure that HIV-infected persons with TB are diagnosed and treated appropriately.…”

Section: Prevent Tbmentioning

confidence: 99%

Tuberculosis control in South Africa: Successes, challenges and recommendations

et al. 2014

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“…At the time of study implementation, limited data were available about the performance of the WHO algorithm in sub-Saharan Africa. Although a few prospective studies have since evaluated the performance of the WHO clinical screening algorithm for TB among PLHIV, the majority of studies have not assessed implementation of screening by healthcare workers routinely providing care to PLHIV and even fewer have assessed the performance of screening among pregnant women [6–11]. In this paper, we describe our evaluation of the performance of routine TB ICF algorithms among PLHIV newly enrolling in HIV services, including prevention of mother-to-child HIV transmission (PMTCT) services, in a high HIV and TB burden region of Western Kenya.…”

Section: Introductionmentioning

confidence: 99%

Performance of Clinical Screening Algorithms for Tuberculosis Intensified Case Finding among People Living with HIV in Western Kenya

et al. 2016

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ObjectiveTo assess the performance of symptom-based screening for tuberculosis (TB), alone and with chest radiography among people living with HIV (PLHIV), including pregnant women, in Western Kenya.DesignProspective cohort studyMethodsPLHIV from 15 randomly-selected HIV clinics were screened with three clinical algorithms [World Health Organization (WHO), Ministry of Health (MOH), and “Improving Diagnosis of TB in HIV-infected persons” (ID-TB/HIV) study], underwent chest radiography (unless pregnant), and provided two or more sputum specimens for smear microscopy, liquid culture, and Xpert MTB/RIF. Performance of clinical screening was compared to laboratory results, controlling for the complex design of the survey.ResultsOverall, 738 (85.6%) of 862 PLHIV enrolled were included in the analysis. Estimated TB prevalence was 11.2% (95% CI, 9.9–12.7). Sensitivity of the three screening algorithms was similar [WHO, 74.1% (95% CI, 64.1–82.2); MOH, 77.5% (95% CI, 68.6–84.5); and ID-TB/HIV, 72.5% (95% CI, 60.9–81.7)]. Sensitivity of the WHO algorithm was significantly lower among HIV-infected pregnant women [28.2% (95% CI, 14.9–46.7)] compared to non-pregnant women [78.3% (95% CI, 67.3–86.4)] and men [77.2% (95% CI, 68.3–84.2)]. Chest radiography increased WHO algorithm sensitivity and negative predictive value to 90.9% (95% CI, 86.4–93.9) and 96.1% (95% CI, 94.4–97.3), respectively, among asymptomatic men and non-pregnant women.ConclusionsClinical screening missed approximately 25% of laboratory-confirmed TB cases among all PLHIV and more than 70% among HIV-infected pregnant women. National HIV programs should evaluate the feasibility of laboratory-based screening for TB, such as a single Xpert MTB/RIF test for all PLHIV, especially pregnant women, at enrollment in HIV services.

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Undiagnosed Tuberculosis Among HIV Clinic Attendees

Cited by 35 publications

References 19 publications

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

Tuberculosis control in South Africa: Successes, challenges and recommendations

Performance of Clinical Screening Algorithms for Tuberculosis Intensified Case Finding among People Living with HIV in Western Kenya

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