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