A home tracing program for contacts of people with tuberculosis or HIV and patients lost to care.

THE DUAL epidemics of tuberculosis (TB) and human immunodeficiency virus (HIV) continue to pose a public health problem in resource-poor countries, particularly sub-Saharan Africa.1 Un-awareness of TB and HIV status prevents individuals from receiving care and results in preventable morbidity, mortality and ongoing transmission.2-4 While facility-based active TB case finding in people living with HIV (PLHIV) and provider-initiated HIV counseling and testing (HCT) for people with TB have become routine, TB contact investigation remains a low priority in high-burden settings. Household contacts are at high risk of infection and disease,5,6 and contact investigation may result in earlier diagnosis.7,8 Home-based TB screening and HCT could also reduce the socio-economic barriers and stigma posed by screening at health care facilities.9 The growing evidence of a large pool of undetected TB in the community7,10-12 has increased interest in contact investigations in these settings. In 2012, the World Health Organization (WHO) published recommendations for investigating contacts of TB cases in low- and middle-income countries.13 The guidelines recommend contact investigations for index cases with smear-positive TB, multidrug-resistant TB, PLHIV or those aged <5 years. They also recommend prioritization of contacts with symptoms suggestive of TB, age <5 years or PLHIV. The guidelines state, in addition, that HCT should be offered as part of TB contact investigation to all contacts in high HIV burden settings, contacts of an HIV-infected index case living with HIV, and contacts with TB symptoms. As the guidelines do not advise on implementation, the optimal strategy remains unclear.14 We aimed to evaluate a pragmatic approach to TB and HIV contact investigation by combining these activities with tracing individuals lost to TB and HIV care. We assessed the program’s yield in identifying cases of undiagnosed TB and HIV, its effectiveness in linking newly diagnosed individuals to care and its success in re-engaging individuals lost to care.