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Low implementation of Xpert MTB/RIF among HIV/TB co-infected adults in 19 low- and middle-income countries
Lesley Odendal, 2015-12-21 13:10:00
Three quarters of people with HIV/TB co-infection did
not receive Xpert MTB/RIF testing for TB diagnosis between 2012 and 2014,
according to a survey of cohorts in 19 low- and middle-income countries by the
International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium, presented
by Dr Kate Clouse at the 46th Union World Conference on Lung Health in Cape
Town from 2 to 6 December.
Since 2011, the World Health Organization (WHO) has
recommended Xpert MTB/RIF as the initial
TB diagnostic test in individuals who may have multi-drug resistant TB or
HIV-associated TB. Xpert MTB/RIF is a rapid test for identification of TB and
rifampicin resistance. The test is being rolled out as a newer diagnostic for TB
management in countries with a high burden of TB and HIV co-infection and has
been shown to reduce treatment gaps and delays in treatment initiation in South
Reducing the time between identification of symptoms
that suggest TB and the start of treatment is critically important. A long
delay between seeking health care and starting treatment increases the risk of
death from TB. People with TB may be lost from care and in the meantime pass on
TB to their close contacts.
The retrospective survey used patient-level data on
HIV and TB diagnosis and treatment, and outcomes were collected from an
observational cohort of adults with HIV diagnosed with TB from 2012
to 2014, who were enrolled in the HIV care programme at an IeDEA site.
The countries included in the survey are Benin,
Burundi, Cameroon, Côte d’Ivoire, Mali, Rwanda, the Democratic Republic of
the Congo, Senegal, South Africa, Uganda, Philippines, Brazil, Honduras, Mexico and
Peru, where one site was surveyed for each country. 20 sites were surveyed in
Kenya, and two each in Tanzania, Thailand and Vietnam. All site-level data was
completed once by the facility manager in mid-2012 and included data collected
on the type of HIV and TB services provided by the facility or externally.
The median CD4 count was 115 cells/mm3 (IQR:
40 – 248 cells/mm3). 47% (n = 1255) were diagnosed with TB in 2012,
38% (n = 1044) in 2013 and 16.3% (n = 448) in 2014. 41% were female and 59% male
and the median age was 35 years (IQR: 29 – 42).
The survey of 2747 people with TB/HIV co-infection found
that 64.8% (n = 1780) of TB cases were not bacteriologically
confirmed by Xpert MTB/RIF, smear microscopy, culture or other nucleic acid amplification test (NAAT) and
treatment was started empirically.
The Xpert MTB/RIF tests had
results documented for 4.8% (n = 133) of the cases surveyed, after 19.5% (n = 536)
of the results were declared missing. 39.1% (n = 52) were negative for TB and
60.9% (n = 81) were diagnosed as positive for TB. 18.5 % (n = 15) of those were
found to be resistant to rifampicin.
The survey found no association between documentation
of Xpert MTB/RIF test and favourable (cured or completed treatment) TB outcome
(RR = 1.02, 95% CI: 0.86 – 1.22), when adjusting for site and year of diagnosis
using inverse probability weighting.
In the TB treatment outcome results, 1727 (62.9%) had
been cured or completed treatment, while 615 (22.4%) had unfavourable outcomes,
including treatment failure, default, death or unknown outcomes). 52 (1.9%)
were still on therapy, 117 (4.3%) had been transferred and 236 (8.6%) had been
lost to follow-up.
Limitations of the study included that data for HIV/TB
cases could not be collected in all settings and the choice of cases was up to
the local team at sites. There is also a potential for unmeasured confounders
such as the timing or use of empiric TB therapy.
“Although the majority of sites had access to Xpert
MTB/RIF, three-quarters of TB cases received no such test. Operational research
must address global implementation challenges of Xpert MTB/RIF testing,” said