Abstract
The focused assessment with sonography for HIV-associated tuberculosis (TB) (FASH) ultrasound protocol has been increasingly used to help clinicians diagnose TB. We sought to quantify the diagnostic utility of FASH for TB among individuals with HIV in Malawi. Between March 2016 and August 2017, 210 adults with HIV who had 2 or more signs and symptoms that were concerning for TB (fever, cough, night sweats, weight loss) were enrolled from a public HIV clinic in Lilongwe, Malawi. The treating clinicians conducted a history, physical exam, FASH protocol, and additional TB evaluation (laboratory diagnostics and chest radiography) on all participants. The clinician made a final treatment decision based on all available information. At the 6-month follow-up visit, we categorized participants based on clinical outcomes and diagnostic tests as having probable/confirmed TB or unlikely TB; association of FASH with probable/confirmed TB was calculated using Fisher's exact tests. The impact of FASH on empiric TB treatment was determined by asking the clinicians prospectively about whether they would start treatment at 2 time points in the baseline visit: (1) after the initial history and physical exam; and (2) after history, physical exam, and FASH protocol. A total of 181 participants underwent final analysis, of whom 56 were categorized as probable/confirmed TB and 125 were categorized as unlikely TB. The FASH protocol was positive in 71% (40/56) of participants with probable/confirmed TB compared to 24% (30/125) of participants with unlikely TB (odds ratio=7.9, 95% confidence interval=3.9,16.1; P<.001). Among those classified as confirmed/probable TB, FASH increased the likelihood of empiric TB treatment before obtaining any other diagnostic studies from 9% (5/56) to 46% (26/56) at the point-of-care. For those classified as unlikely TB, FASH increased the likelihood of empiric treatment from 2% to 4%. In the setting of HIV coinfection in Malawi, FASH can be a helpful tool that augments the clinician's ability to make a timely diagnosis of TB.
Highlights
The risk of developing active tuberculosis (TB) is 20–37 times higher in people living with HIV than in people who do not have HIV.[1]
The 14 participants who died during the study were included in the final analysis, including 2 participants with confirmed TB, and categorized and 12 without laboratory confirmation and were categorized as unlikely TB
Of the 181 participants included in the final analysis, we classified 56 as probable/confirmed TB (20 microbiologically confirmed and 36 probable) and 125 as unlikely TB
Summary
The risk of developing active tuberculosis (TB) is 20–37 times higher in people living with HIV than in people who do not have HIV.[1] This risk is compounded by difficulty in diagnosing TB in individuals who have HIV, as they more commonly present with atypical radiographic findings, smear-negative TB, and disseminated extrapulmonary manifestations.[2] As a result, individuals with HIV and TB have a higher mortality rate, likely due to diagnostic uncertainty that leads to delays in therapy.[3] Gold standard diagnostics, such as TB. Diagnostic Utility of Focused Assessment With Sonography on HIV-Associated Tuberculosis www.ghspjournal.org culture, are often unavailable in regions with the highest burden of TB and HIV. Even when these diagnostics are available, the results can take up to 6 weeks to return, causing delays in diagnosis and treatment.
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