Abstract
IntroductionTuberculosis (TB) is the leading cause of HIV‐associated mortality in Africa. As HIV testing, linkage to care and antiretroviral treatment initiation intensify to meet UNAIDS targets, it is not known what effect these efforts will have on TB detection and prevention. We aimed to characterize the TB care cascade of screening, diagnostic testing, treatment and provision of isoniazid preventive therapy (IPT) in a study of community‐based HIV screening and linkage to care and determine whether symptom screening results affected progress along the cascade.MethodsBetween June 2013 and March 2015, HIV‐infected adults enrolled in the Linkages study, a multi‐site, community‐based, randomized HIV screening and linkage‐to‐care study in South Africa and Uganda. All participants were screened for TB symptoms at entry after testing positive for HIV and referred to local clinics for care. During the 9 month follow‐up, participants were periodically surveyed about clinic linkage and initiation of HIV care as well as subsequent TB testing, treatment, or IPT. We compared outcomes between persons with and without a positive symptom screen at baseline using descriptive statistics and Poisson regression to calculate relative risks of outcomes along the care cascade.Results and discussionOf the 1,325 HIV‐infected adults enrolled, 26% reported at least one TB symptom at the time of HIV diagnosis. Loss of appetite and fever were the most commonly reported symptoms on a TB symptom screen. Despite 92% HIV linkage success, corresponding TB linkage was incomplete. Baseline TB symptoms were associated with an increased risk of a TB diagnosis (relative risk 3.23, 95% CI 1.51 to 6.91), but only 34% of symptomatic persons had sputum TB testing. Fifty‐five percent of participants diagnosed with TB started TB treatment. In South Africa, only 18% of asymptomatic participants initiated IPT after linkage to HIV care, and presence of symptoms was not associated with IPT initiation (relative risk 0.86 95% CI 0.6 to 1.23).Conclusions HIV linkage to care interventions provide an opportunity to improve completion of the TB care cascade, but will require additional support to realize full benefits.
Highlights
Tuberculosis (TB) is the leading cause of HIV-associated mortality in Africa
We evaluated participant progress through the stages of the “TB care cascade” (Figure 1), including screening yield, diagnostic testing, results of testing, and treatment or preventive therapy initiation in a community-based HIV testing programme in South Africa and Uganda that was designed to increase knowledge of HIV serostatus and linkage to HIV care
Linkage to HIV clinics was high (92%) and there was no difference in clinic linkage among patients with or without TB symptoms at baseline (RR=1.01, 95% CI 0.98 to 1.05, p = 0.38)
Summary
Tuberculosis (TB) is the leading cause of HIV-associated mortality in Africa. As HIV testing, linkage to care and antiretroviral treatment initiation intensify to meet UNAIDS targets, it is not known what effect these efforts will have on TB detection and prevention. The WHO recommends intensive case-finding for TB in people with HIV, consisting for adults and adolescents of a 4-question symptom screen (presence of cough, fevers, night sweats and weight loss) and subsequent evaluation for TB if symptoms are present, as well as isoniazid preventive therapy (IPT) for HIVinfected people without active TB [2]. Despite these recommendations, screening and linkage into care for TB treatment and IPT among HIV-infected persons remains low [3]. We evaluated participant progress through the stages of the “TB care cascade” (Figure 1), including screening yield, diagnostic testing, results of testing, and treatment or preventive therapy initiation in a community-based HIV testing programme in South Africa and Uganda that was designed to increase knowledge of HIV serostatus and linkage to HIV care
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