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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

1
University of California, San Francisco, Medicine, San Francisco, United States ; Christina.Yoon@ucsf.edu.
2
Makerere University College of Health Sciences, 58589, Kampala, Uganda.
3
Makerere University Joint AIDS Program, Kampala, Uganda.
4
Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda.
5
Johns Hopkins University, 1466, Baltimore, Maryland, United States.
6
Johns Hopkins University Bloomberg School of Public Health, 25802, Baltimore, Maryland, United States.
7
University of California, San Francisco, Epidemiology and Biostatistics, San Francisco, California, United States.
8
University of California, San Francisco, Medicine, San Francisco, California, United States.

Abstract

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.

MAIN RESULTS:

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.

CONCLUSIONS:

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.

KEYWORDS:

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

PMID:
30192649
DOI:
10.1164/rccm.201803-0490OC

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