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Ugandan experience shows TB detection can be successfully incorporated into community HIV testing campaigns
Michael Carter, 2016-09-16 08:00:00
campaigns provide an opportunity to detect previously undiagnosed cases of
tuberculosis (TB), investigators report in the online edition of the Journal of Acquired Immune Deficiency
Syndromes. Research conducted in rural Uganda showed that incorporating TB
screening into community health campaigns offering universal HIV testing led to
the diagnosis of undetected TB cases. Overall, approximately 3000 patients need
to be screened to identify one new case of TB, but among patients with HIV and
chronic cough, the yield was one new TB diagnosis per 80 screens.
“Our data suggest
that coupling population-based HIV and TB testing within a multi-disease health
campaign approach provides an innovative method to increase detection of
smear-positive TB cases while rapidly increasing HIV testing coverage,” write
the authors. “The burden of undiagnosed TB disease and the number needed to
screen and identify one new TB case are within the range of prior estimates
from TB prevalence surveys in sub-Saharan Africa.”
Globally, HIV and
TB are a leading cause of death due to infectious disease. Even though
effective antibiotic therapy is available, TB remains an important cause of
mortality in East Africa, largely because of late diagnosis and under-diagnosis
of the infection.
wanted to see if shifting TB detection out of clinical settings and into the
community would lead to the detection of previously undiagnosed cases of the
infection. They therefore analysed data obtained from a multi-disease community
health campaign conducted between 2013-14 in seven rural communities in eastern
The study forms part of the larger SEARCH study, an investigation of the effectiveness of mutli-disease prevention campaigns in maximising HIV diagnosis, treatment and viral suppression in the east African setting.
TB screening was
incorporated into population-wide HIV testing. Study staff worked with local
community leaders to identify all eligible adults and to promote the community
health campaign. For a two-week period, HIV testing, together with screening
for TB and other health conditions, were provided at well-known and convenient
community locations. Patients were offered a rapid HIV test, and individuals
testing positive had point-of-care CD4 monitoring and were linked to ongoing
care. For TB screening, all patients were asked if they had a cough, and if
this was present if it was persistent, lasting for more than two weeks.
Participants with a prolonged cough were asked to provide a spontaneous sputum
sample which was sent for microscopy evaluation with results returned the same
day. Staff contacted all patients with positive microscopy results.
A total of 36,785 adults
were identified in the baseline census and 27,214 (74%) of these individuals
attended a community health campaign. The median age of those attending was 30
years and 57% were women. Almost all (99%) accepted the offer of an HIV test,
with 3.5% testing positive.
Cough was reported
by 5,786 (21%) of participants and 2,876 (11%) reported a persistent cough. The
rate of persistent cough was higher in older patients, in women compared to men
(11.4% vs. 9.5%, p < 0.001) and in HIV-positive rather than HIV-negative
patients (17% vs. 10%).
Only 38% of
patients with a persistent cough were able to expectorate sputum. Factors
associated with being able to produce a sputum sample were older age (p <
0.001) and HIV-positive status (p < 0.001).
from ten patients were positive for acid-fast bacilli. Three of the patients
were HIV-positive, and one of these individuals was newly diagnosed with HIV
thanks to the community health campaign.
Nine of the TB
diagnoses were new; the other case had previously been detected at a local
health centre. Six of the new cases had microscopy results suggesting their TB
was highly contagious.
Overall, 0.31% of
patients were newly diagnosed with TB. The number of patients needed to screen using
symptoms and microscopy to identify a single new case was 3,024. The number of
patients with prolonged cough who required screening with microscopy to
identity a new case was 320, the figure falling to 80 per case for HIV-positive
patients with chronic cough.
All nine patients
with newly detected TB were linked to care and initiated TB therapy. This
treatment was completed by six patients. One individual experienced treatment
failure and initiated a second-line regimen; one individual was lost to follow-up;
one patient died of trauma before completing their treatment.
The investigators acknowledge their study was limited by the lack of a cost-effectiveness analysis.
community health campaign approach provided an opportunity to increase TB case
detection and treatment and to reduce the burden of undiagnosed TB disease in
rural Uganda, in the context of population-wide, HIV testing scale-up,”
conclude the authors.