Catching the missing million: experiences in enhancing TB & DR-TB detection by providing upfront Xpert MTB/RIF testing for people living with HIV in India.

Neeraj Raizada,Radhey Shyam Gupta,Catharina Boehme,Chinnambedu Nainarappan Paramsivan,Achuthan Sreenivas,Shubhangi Kulsange,Puneet Dewan,Kuldeep Singh Sachdeva,Rahul Thakur,Pere-Joan Cardona

doi:10.1371/journal.pone.0116721

Neeraj Raizada, Radhey Shyam Gupta + Show 8 more

Open Access

https://doi.org/10.1371/journal.pone.0116721

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Abstract

BackgroundA critical challenge in providing TB care to People Living with HIV (PLHIV) is establishing an accurate bacteriological diagnosis. Xpert MTB/RIF, a highly sensitive and specific rapid tool, offers a promising solution in addressing these challenges. This study presents results from PLHIV taking part in a large demonstration study across India wherein upfront Xpert MTB/RIF testing was offered to all presumptive PTB cases in public health facilities.MethodThe study covered a population of 8.8 million across 18 sub-district level tuberculosis units (TU), with one Xpert MTB/RIF platform established at each TU. All HIV-infected patients suspected of TB (both TB and Drug Resistant TB (DR-TB)) accessing public health facilities in study area were prospectively enrolled and provided upfront Xpert MTB/RIF testing.Result2,787 HIV-infected presumptive pulmonary TB cases were enrolled and 867 (31.1%, 95% Confidence Interval (CI) 29.4‒32.8) HIV-infected TB cases were diagnosed under the study. Overall 27.6% (CI 25.9–29.3) of HIV-infected presumptive PTB cases were positive by Xpert MTB/RIF, compared with 12.9% (CI 11.6–14.1) who had positive sputum smears. Upfront Xpert MTB/RIF testing of presumptive PTB and DR-TB cases resulted in diagnosis of 73 (9.5%, CI 7.6‒11.8) and 16 (11.2%, CI 6.7‒17.1) rifampicin resistance cases, respectively. Positive predictive value (PPV) for rifampicin resistance detection was high 97.7% (CI 89.3‒99.8), with no significant difference with or without prior history of TB treatment.ConclusionThe study results strongly demonstrate limitations of using smear microscopy for TB diagnosis in PLHIV, leading to low TB and DR-TB detection which can potentially lead to either delayed or sub-optimal TB treatment. Our findings demonstrate the usefulness and feasibility of addressing this diagnostic gap with upfront of Xpert MTB/RIF testing, leading to overall strengthening of care and support package for PLHIV.

Highlights

A critical challenge in providing TB care to People Living with HIV (PLHIV) is establishing an accurate bacteriological diagnosis
The study results strongly demonstrate limitations of using smear microscopy for TB diagnosis in PLHIV, leading to low TB and DR-TB detection which can potentially lead to either delayed or sub-optimal TB treatment
Our findings demonstrate the usefulness and feasibility of addressing this diagnostic gap with upfront of Xpert MTB/RIF testing, leading to overall strengthening of care and support package for PLHIV

Summary

Methods

SettingIndia's national TB program covers a population of 1.2 billion through a network of 662 district TB programme units and 2,698 sub-district TB programme units referred to as Tuberculosis units (TUs).Each TU covers a population of approximately 0.5 million. 8 sites were in rural areas catering to a population of 3.9 million, 6 sites were in urban areas catering to a population of 3.4 million and 4 sites were in tribal and hilly area covering a population of 1.5 million (Fig. 1). These 18 sites account for 8.8 million people having access to TB diagnostic services through 99 DMCs and their corresponding linked health facilities

Results

Discussion

Conclusion