Living with HIV, Dying of TB
Intensified TB case finding among people living with HIV
Adapted from presentation by Colleen Daniels
TB/HIV Advocacy
Stop TB Department, WHO
Outline of presentation
• What is intensified case finding?
• Global implementation of TB case finding
• Challenges
• Conclusions
Intensified Case Finding (ICF)
• Intensified TB case finding (ICF) is an activity, recommended by the World Health Organization (WHO), intended to detect possible TB cases as early as possible among people living with HIV
– Screening for symptoms and signs of TB
• + TB treatment
• TB sputum smear • - IPT
• ICF is the first step towards making a TB diagnosis.
Intensified Case Finding (ICF)
• TB control programs generally rely on passive TB case finding
• People living with HIV are at much greater risk of getting TB and if not treated soon enough, dying from it – often aggressive cases including hard-to-diagnose
smear-negative or extrapulmonary disease.
• ICF consists of using a simple questionnaire looking for the signs and symptoms of TB.
Percentage of PLHIV screened for TB in countries with 80% of the global burden, 2006.
1.83
0.00
0.77
0.00 0.00 0.05 0.00
1.07
0.00 0.00
0.31
0.00
0.78
0.96
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
South Africa
KenyaNigeriaMalawiZimbabwe
Mozambique
ZambiaIndia
DR CongoUR Tanzania
EthiopiaUgandaRwandaGlobal
Proportion of PLHIV screened and diagnosed with TB in selected countries, 2006
0
20,000
40,000
60,000
80,000
100,000
120,000
South Africa Mozambique India Ethiopia
PLHIV screened for TB
PLHIV with TB after screening
29%
8% 20% 31%
Country Screening Tools
National screening strategy: Kenya
Symptoms and signsAdults (any of)
1. Cough (of any duration)?2. Blood stained sputum?3. Night sweats >2 weeks4. Fever ?5. Weight loss?6. Chest pain?7. Breathlessness?8. Fatigue?9. History of previous TB treatment?10. History of close contact with a
person confirmed to have TB? 11. Swellings in the neck, armpits or
elsewhere?12: Diarrhea for more than two weeks?
Symptom and signsChildren (any of)
1. Cough: (of any duration)? 2. Blood stained sputum?3. Night sweats >2 weeks4. Fever? Of any duration?5. Weight loss?6. Chest pain?7. Fast Breathing?8. Fatigue?9. History of previous TB treatment?10. History of close contact with a
person confirmed to have TB? 11. Swellings in the neck, armpits or
elsewhere?12: Diarrhea for more than 2 weeks?13. Failure to thrive?
National screening strategy: Malawi
Any of the following
• Cough more than 3wks• Weight loss• Fever or night sweats• Fatigue/tiredness• Loss of appetite • Lymph node enlargement
Screening tools in countries
• Screening tools vary from country to country
• More and more non-specific constitutional symptoms and signs included in tools
• Children are not addressed
• Presence of nationally recommended screening tool does not always guarantee implementation
Challenge: implementation issues
• Standardised screening tool needed?
• Screening tool that can rule out active TB disease is needed and how best to link it with IPT?
• Who administers the standard tool and where?
• How often should it be administered?
• Monitoring and evaluation- how should it be recorded and reported?
Review of some published evidence of TB screening strategies
Kimerling, et.al – Cambodia,2002IJTLD 2002; 6:988–994
Population 441 HIV+ in home-based care
Gold stn. Single sputum culture
# with TB 41 (9%) with culture-confirmed TB
Cough Cough >3 weeks 65% sensitive, 33% specific
Algorithm Any 1 of: - cough>3 wks - hemoptysis - weight loss - fever - night sweats - weakness No information on role of CXR
Sensitivity= 95%Specificity= 10%
Day, et. al. – South Africa, 2006IJTLD 2006: 10:523-529
Population 899 HIV-infected miners being evaluated for IPT
Gold Stn. Culture positive or clinical improvement
# with TB 44 (5%) patients met definition for TB, 35 culture +
Cough Cough >3 weeks 14% sensitive, 88% specific
Algorithm • Any 1 of - night sweats - new or worsening cough - weight loss >5%
- abnormal CXR. • Combination of - night sweats - cough - reported weight loss
CXR increased the sensitivity of the screening
Sensitivity= 91%Specificity= 59%
Sensitivity= 59%Specificity= 76%
Demissie, et.al. – EthiopiaWorld Lung Health Conference 2007 Abstract S11
Setting Addis Ababa, Ethiopia – community hospital
Study pop. 438 newly diagnosed HIV+
Gold Stn. Concentrated sputum smear and culture
# with TB 32 (7%) with culture-confirmed TB
Cough Cough> 2 wks is 44% sensitive, 76% specific
Algorithm Cough or fever – 75% sensitivity, 57% specificityCXR improved sensitivity to 91% (at a cost of specificity)
Some Notes and Observations from available evidence
• Sesitivity: Ability of the test to accurately diagnose the presence of disease.
• Specificity: Ability of the test to accurately identify all people without the conditionThese are both measures of accuracy of a screening tool to identify a person with TB, the higher the Sensitivity and Specificity the more accurate the tool.
• The accuracy of screening are generally inconsistent and dependent what types of screening questions are asked. Eg: the more the symptoms the greater the chances of detecting anyone with TB, but also the greater the chances of wrongly suspecting that people have TB when they don’t.
• Chronic cough more than 2 or 3 wks alone looks insensitive predictor of TB in PLHIV
• Role of CXR is not clear and inconsistent
Living with HIV, Dying of TB Conclusions
• People with HIV have the right to ask for TB screening and diagnosis.
• Check your country's progress in implementing the 12 collaborative activities and engage with the NTP and NAP to call for scale up (Global TB Report)
Conclusions
• Mobilization by civil society urgently needed to scale up ICF. – Community driven to create demand– Educate – increase literacy in communities and at
health care facilities– Work with joint TB/HIV national mechanisms to
rapidly scale up– Engage in processes such as Global Fund CCMs – Demand creation– Myth busting - ensure that arguments about challenges to
implementation are not a barrier (HIV experience) - Just do it!
Conclusions
• Massive research efforts to develop the best and feasible screening tool are urgently needed– "TB dipstick test"- simple and rapid tool is
crucial
• Call for investment and increase in laboratory capacity and call for adequate referral systems
• Recording and reporting