High Yield of Home-Based TB Diagnosis Among Newly Diagnosed Patients With HIV
Elisa López‐VarelaDurval RespeitoSilvia BlancoManuel GimoCharfudin SacoorDenise NanicheAlberto L. García‐Basteiro
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To the Editors: Tuberculosis (TB) remains an important public health concern and a leading cause of disease and death. People living with HIV (PLHIV) are at a higher risk of developing TB, and TB is the largest cause of death among this population, accounting for 37% of AIDS-related deaths in 2016.1 Early TB diagnosis among PLHIV is crucial for improved patient outcomes, and yet long diagnostic delays in high TB and HIV settings continue to be reported.2 Different active case finding studies have shown the utility and feasibility of home-based (HB) TB testing among TB contacts.3,4 Despite some criticisms about the relative low yield and high costs of these strategies, they have the advantage of expanding heath care access beyond the health system while reducing transmission in the health facilities. Nonetheless, beyond routine screening at the health facility level, there are no specific national guidelines recommending active TB case finding among patients with HIV newly diagnosed at the community or household level. The aim of this study was to determine the community prevalence of pulmonary TB among a cohort of PLHIV newly diagnosed through HB HIV testing and counseling (HTC) in Mozambique. The study was performed in 2015 in the area covered by the health and demographic surveillance system located in the Manhiça District. This is a semirural area in southern Mozambique, with a particularly high HIV and TB burden. The HIV prevalence in the district among adults aged 18–47 years was 39.7% in 2012,5 and the incidence rate of laboratory-confirmed TB was 847/100,000 among PLHIV.6,7 UNAIDS estimates that in 2017, 59% [95% confidence interval (CI): 49 to 70] of PLHIV in Mozambique knew their status.8 Before study initiation, HIV testing was mainly provided through voluntary counseling and testing. TB diagnosis was mostly based in sputum smear testing, and Xpert MTB/RIF was only performed among retreatment cases or those with a positive culture 2 or 5 months after treatment initiation. This study was nested within a larger cohort of adults older than 18 years newly diagnosed with HIV with independent approval by the national bioethics committee of Mozambique (Ref: 75/CNBS/2014).9 The larger cohort consisted of randomly selected adult individuals living in the Manhiça District Hospital's catchment area diagnosed with HIV through HB-HTC. HB-HTC was performed using a list of adults randomly selected among the residents recorded in the health and demographic surveillance system. Three attempts were made to contact each individual before defining the status as absent, and replacement was used when household residents could not be found. Only PLHIV with previously negative or reported unknown HIV status were eligible to participate. Enrollment into the TB study was done in the same visit in which the patient was HIV diagnosed by community-based workers trained in HTC and in basic TB-screening procedures. Individuals consenting to participate were screened for TB following the World Health Organization symptom–based screening algorithm (reported fever, cough, night sweats, and weight loss).10 All patients, regardless of the presence of any TB-compatible symptoms, were asked to provide a spontaneous spot sample of sputum, which was collected outdoors following specific infection control training. Samples were transported to the study laboratory for Xpert MTB/RIF, and smear and liquid culture testing. Patients with TB-compatible symptoms were referred to the closest health facility for clinical management. Patients with any positive test were further contacted for TB treatment initiation. All newly diagnosed PLHIV were referred to the Manhiça District Hospital HIV chronic care clinic for enrollment in care and routine follow-up. Those who successfully linked to care were passively followed up for a year, to assess TB incidence. Passive follow-up clinical data were obtained from the MDH HIV clinical records. The number needed to screen (NNS) and the number needed to test for a laboratory-confirmed TB case were calculated by dividing the number of participants consenting to participate and those providing a sample, respectively, among the number of confirmed TB cases. Among 318 PLHIV diagnosed through HB-HTC, 97.2% (309) consented to participate. Fifty-seven (18.4%) were later identified as previous HIV cases who did not disclose their HIV status, and thus, 252 PLHIV (81.6%) were finally included in the analysis. Among them, the mean age was 35.9 years (SD: 14.0) and 56.2% were women. A total of 104 (41.3%) described any of the following symptoms: cough of any duration: 58 (55.8%); fever: 35 (33.7%); weight loss: 51 (49.0%); and night sweats: 53 (51.0%). Twenty-one patients (8.3%) reported having a household member with TB in the previous year and 4 (1.6%) reported having a previous history of TB treatment. Ninety-one participants (36.1%) were able to provide a spontaneous sputum sample, of whom 32 were asymptomatic (Fig. 1). Four participants had laboratory-confirmed TB, one of whom was asymptomatic and one had history of previous TB treatment. Eight participants had a nontuberculous mycobacteria isolated (M. intracellulare n = 3; M. spp n = 3, M. peregrinum n = 1, and M. scrofulaceum n = 1) The prevalence of laboratory-confirmed TB among newly diagnosed PLHIV was 1.6% (4/252) (95% CI: 0.4 to 4.0). The prevalence of laboratory-confirmed TB was 4.4% (4/91) (95% CI: 1.2 to 10.9) and 2.9% (3/104) (95% CI: 0.6 to 8.2) among those providing samples and among patients who had a positive screen for TB, respectively (Fig. 1). The NNS for a laboratory-confirmed TB case was 63 and the number needed to test was 23.FIGURE 1.: Study flowchart and overall results from community TB screening and testing among newly diagnosed HIV individuals.Linkage to HIV care, defined as having a CD4 count test in the following 12 months after diagnosis, was 37.3% (94/252) for all participants. The median initial CD4 cell count was 328 cells/mL (interquartile range 195–505). Three of the 4 confirmed TB cases linked to care with a median CD4 of 208 (interquartile range 52–1061). Among the remaining newly diagnosed HIV participants linked to care, 2 additional TB cases were diagnosed in the following year, yielding a TB incidence of 2.2% (95% CI: 0.3 to 7.7). This is one of the few studies reporting on single encounter–coupled HIV and TB testing at the patient household in sub-Saharan Africa.3,11–13 Importantly, we found a high participation rate for TB screening and testing in a population of newly diagnosed HIV participants. Although the sample size is limited, the prevalence of microbiologically confirmed TB among newly diagnosed patients is high, taking into account that this population (with unknown or previously negative HIV status) is unlikely to be severely immunosuppressed. The prevalence and incidence are in line with previous burden of disease assessments conducted in the district based on health facility–based TB diagnoses.6 The NNS falls within the range of other studies in sub-Saharan Africa.11 Nonetheless, the NNS is, as expected, higher than the weighted mean (NNS: 10) obtained in a systematic review that included facility-based patients with HIV.14 This study had some limitations. First, it was a nested in a larger cohort, thus the sample size was not a priori calculated and was small. Second, we only collected one spot sputum sample at the time of the visit, far from the recommendations of most optimal sample collection procedures (at least 2 samples, one of them at the early morning). Finally, patient's follow-up was passive, and thus, it is likely that the true prevalence at the time of HIV diagnosis, as well as the incidence rate during the first-year postscreening, is underestimated. In conclusion, we found a high TB prevalence among newly diagnosed patients with HIV in the community. Joint TB and HIV testing strategies performed at the household level are feasible in rural settings and contribute to early diagnosis of both conditions. The recommendations of TB screening among PLHIV are supported by World Health Organization recommendations, although further on guidance on household-level implementation needs to be provided. Cost-effectiveness of this intervention and further studies with larger sample size that include patient follow-up to assess in individual-level benefits in treatment outcomes need to be conducted.Cite
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