Yield and Efficiency of Novel Intensified Tuberculosis Case-Finding Algorithms for People Living with HIV

Abstract

POC CRP-based screening can improve ICF efficiency among PLHIV. Addition of TB-LAM and a single culture to Xpert confirmatory testing could enable HIV programs to increase the speed of TB diagnosis and ICF yield.

Bundling HIV and TB Care at a District-Level Center in Sierra Leone: A high-yield method for diagnosing co-infection with TB and antiretroviral treatment failure among people living with HIV

“…Our results lend further support to the studies by Shenoi and Carmone that bundled services and checklists for HIV care are effective in closing gaps. Our results also support the body of literature showing that intensified case finding for TB within HIV clinics is acceptable to patients and improves case finding rates (Bigogo et al, 2018;Yoon et al, 2019;Owiti et al, 2019;Sawry et al, 2018;Gupta et al, 2014). Our experience is unique in that we describe an educational and programmatic way to build capacity in existing staff without added cost.…”

Systematic, Point-of-Care Urine Lipoarabinomannan (Alere TB-LAM) Assay for Diagnosing Tuberculosis in Severely Immunocompromised HIV-Positive Ambulatory Patients

“…Some studies of pre-ART patients have found LAM useful for diagnosing TB. 7,8,11,13 In our study, half of the LAMpositive patients were on ART, and ART-naive patients did not have a higher likelihood of being LAM positive than those on ART, suggesting systematic LAM's utility for diagnosing TB in severely immunosuppressed patients, regardless of their ART status. A South African study of patients under HIV care found very low LAM positivity, 6 although high degrees of immunosuppression in our study population (median CD4 was 31 cells/μL compared with 111 cells/μL in Hanifa et al study) may partially explain this difference.…”

“…4,5 Diagnostic accuracy studies of LAM for TB diagnosis of HIV-positive patients irrespective of signs and symptoms have provided inconsistent results. [6][7][8][9][10][11][12][13] In a recent systematic review, the sensitivity and specificity of LAM in outpatients, irrespective of their TB symptoms, was 31% and 95%, respectively, 14 and the just published WHO TB-LAM revised guidelines recommend the use of LAM in HIV-positive patients with CD4 count les than 100 cells/μL, irrespective of signs and symptoms of TB 15 We assessed LAM results and TB diagnosis in ambulatory, severely immunosuppressed HIV patients, who had LAM systematically performed at new or regular HIV consultations. We also assessed the association between LAM results and mortality at 6 months.…”

Improving Tuberculosis Case Finding in Persons Living with Advanced HIV through New Diagnostic Algorithms

“…In this issue of the Journal , Yoon and colleagues (pp. 643–650 ) report findings from a large, prospectively followed cohort of HIV-infected patients and contribute two important advances ( 12 ). First, they were able to evaluate and compare the accuracy of several novel diagnostic algorithms that include CRP, Determine TB-LAM, Xpert MTB/RIF, and culture with the current global guideline for intensified case finding.…”

“…A key challenge is that both algorithms—symptom screening and CRP testing, followed by sputum Xpert—have inadequate sensitivity, estimated in this study at 59% and 56%, respectively. Yoon and colleagues ( 12 ) demonstrate that the screening resources saved by using CRP tests rather than symptom screening could be used for confirmatory testing by TB-LAM (for those with CD4 < 100) and sputum culture in addition to Xpert. This approach improves the overall diagnostic yield to 78% while containing costs, resulting in a cost per tuberculosis case diagnosed of $92 (compared with $102 for symptom screening followed by Xpert).…”