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Am J Respir Crit Care Med. 2018 Sep 7. doi: 10.1164/rccm.201803-0490OC. [Epub ahead of print]

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

Author information

University of California, San Francisco, Medicine, San Francisco, United States ;
Makerere University College of Health Sciences, 58589, Kampala, Uganda.
Makerere University Joint AIDS Program, Kampala, Uganda.
Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda.
Johns Hopkins University, 1466, Baltimore, Maryland, United States.
Johns Hopkins University Bloomberg School of Public Health, 25802, Baltimore, Maryland, United States.
University of California, San Francisco, Epidemiology and Biostatistics, San Francisco, California, United States.
University of California, San Francisco, Medicine, San Francisco, California, United States.


Rationale/Objectives: The recommended tuberculosis (TB) intensified case finding (ICF) algorithm for people living with HIV (PLHIV) - symptom-based screening followed by Xpert MTB/RIF (Xpert) testing - is insufficiently sensitive and results in unnecessary Xpert testing. We evaluated whether novel ICF algorithms combining C-reactive protein (CRP)-based screening with urine Determine TB-LAM (TB-LAM), sputum Xpert and/or culture could improve ICF yield and efficiency. Methods/Measurements: We compared the yield and efficiency of novel ICF algorithms inclusive of POC CRP-based TB screening and confirmatory testing with urine TB-LAM (if CD4 count ≤100 cells/μL), sputum Xpert, and/or a single sputum culture among consecutive PLHIV with CD4 counts ≤350 cells/uL initiating antiretroviral therapy in Uganda.


Of 1245 PLHIV, 203 (16%) had culture-confirmed TB including 101 (49%) patients with CD4 counts ≤100 cells/μL. Compared to the current ICF algorithm, POC CRP-based screening followed by Xpert testing had similar yield (56% [95% CI: 49-63] vs. 59% [95% CI: 51-65]) but consumed less than half as many Xpert assays per TB case detected (9 vs. 4). Addition of TB-LAM did not significantly increase diagnostic yield relative to the current ICF algorithm but provided same-day diagnosis for 26% of TB patients with advanced HIV. Addition of a single culture to TB-LAM and Xpert substantially improved ICF yield, identifying 78% of all TB cases.


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.


C-reactive protein; HIV; intensified case finding; tuberculosis; urine lipoarabinomannan


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