Tuberculosis (TB) risk varies among different HIV subgroups, potentially impacting intensified case finding (ICF) performance. We evaluated the performance of the current ICF algorithm [symptom screening, followed by Xpert MTB/RIF (Xpert) testing] in 2 HIV subgroups and evaluated whether ICF performance could be improved if TB screening was based on C-reactive protein (CRP) concentrations.
We enrolled consecutive adults with CD4 counts ≤350 cells/µL initiating antiretroviral therapy and performed symptom screening, CRP testing using a low-cost point-of-care (POC) assay, and collected sputum for Xpert testing. We compared the yield and efficiency of the current ICF algorithm to POC CRP-based ICF among patients new to HIV care and patients engaged in care.
Of 1794 patients, 126/1315 (10%) new patients and 21/479 (4%) engaged patients had Xpert-positive TB. The current ICF algorithm detected ≥98% of all TB cases in both subgroups but required ≥85% of all patients to undergo Xpert testing. POC CRP-based ICF halved the proportion of patients in both subgroups requiring Xpert testing relative to the current ICF algorithm and had lower yield among patients engaged in care [81% vs. 100%, difference −19% (95% confidence interval: −41 to 3)]. Among patients new to care, POC CRP-based ICF had similar yield as the current ICF algorithm [93% vs. 98%, difference −6% (95% confidence interval: −11 to 0)].
Among patients new to care, POC CRP-based screening can improve ICF efficiency without compromising ICF yield, whereas symptom-based screening may be necessary to maximize ICF yield among patients engaged in care.
aDepartment of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda;
bMakerere University Joint AIDS Program (MJAP), Kampala, Uganda;
cInfectious Diseases Research Collaboration, Kampala, Uganda; and
dDivision of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA.
Correspondence to: Fred C. Semitala, MBChB, MMed, MPH, Department of Internal Medicine, Makerere University School of Medicine, PO Box 7072, Kampala, Uganda (e-mail: email@example.com).
Supported by the Fogarty International Center of the National Institutes of Health (D43 TW010037 F.C.S.), National Institutes of Health (NIH)/National Institute of Allergy and Infectious Diseases (NIAID; K23 AI114363 to C.Y.); NIH and University of California, San Francisco-Gladstone Institute of Virology and Immunology (UCSF-GIVI) Center for AIDS Research (CFAR; P30 AI027763 to C.Y.); the UCSF Nina Ireland Program for Lung Health; (C.Y.); NIH/NIAID-President's Emergency Plan for AIDS Relief (PEPFAR) CFAR Administrative Supplement (P30 A120163 to A.C.). The funding organizations had no role in the design, collection, analysis, and interpretation of data, or in the writing of the manuscript. We thank the patients and staff of the Makerere University Joint AIDS Program-Immune Suppression Syndrome (ISS) Clinic and The AIDS Support Organization (TASO)-Mulago.
The authors have no conflicts of interest to disclose.
Received April 03, 2019
Accepted July 17, 2019