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Åhsberg J, Tersbøl BP, Puplampu P, Kwashie A, Commey JO, Adusi-Poku Y, Moseholm E, Andersen ÅB, Kenu E, Lartey M, Johansen IS, Bjerrum S. Use of the urine Determine LAM test in the context of tuberculosis diagnosis among inpatients with HIV in Ghana: a mixed methods study. Front Public Health 2024; 11:1271763. [PMID: 38249371 PMCID: PMC10797072 DOI: 10.3389/fpubh.2023.1271763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/30/2023] [Indexed: 01/23/2024] Open
Abstract
Background The urine Determine LAM test has the potential to identify tuberculosis (TB) and reduce early mortality among people living with HIV. However, implementation of the test in practice has been slow. We aimed to understand how a Determine LAM intervention was received and worked in a Ghanaian in-hospital context. Design/Methods Nested in a Determine LAM intervention study, we conducted a two-phase explanatory sequential mixed methods study at three hospitals in Ghana between January 2021 and January 2022. We performed a quantitative survey with 81 healthcare workers (HCWs), four qualitative focus-group discussions with 18 HCWs, and 15 in-depth HCW interviews. Integration was performed at the methods and analysis level. Descriptive analysis, qualitative directed content analysis, and mixed methods joint display were used. Results The gap in access to TB testing when relying on sputum GeneXpert MTB/Rif alone was explained by difficulties in obtaining sputum samples and an in-hospital system that relies on relatives. The Determine LAM test procedure was experienced as easy, and most eligible patients received a test. HCWs expressed that immediate access to Determine LAM tests empowered them in rapid diagnosis. The HCW survey confirmed that bedside was the most common place for Determine LAM testing, but qualitative interviews with nurses revealed concerns about patient confidentiality when performing and disclosing the test results at the bedside. Less than half of Determine LAM-positive patients were initiated on TB treatment, and qualitative data identified a weak link in the communication of the Determine LAM results. Moreover, HCWs were reluctant to initiate Determine LAM-positive patients on TB treatment due to test specificity concerns. The Determine LAM intervention did not have an impact on the time to TB treatment as expected, but patients were, in general, initiated on TB treatment rapidly. We further identified a barrier to accessing TB treatment during weekends and that treatment by tradition is administrated early in the morning. Conclusion The Determine LAM testing was feasible and empowered HCWs in the management of HIV-associated TB. Important gaps in routine care and Determine LAM-enhanced TB care were often explained by the context. These findings may inform in-hospital quality improvement work and scale-up of Determine LAM in similar settings.
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Affiliation(s)
- Johanna Åhsberg
- Research Center of Infectious Diseases, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Mycobacterial Centre for Research Southern Denmark, MyCRESD, Department of Infectious Diseases, Odense University Hospital Odense, Odense, Denmark
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Peter Puplampu
- Department of Medicine and Therapeutics, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | | | | | - Yaw Adusi-Poku
- National Tuberculosis Control Programme, Ghana Health Service, Korle-Bu, Accra, Ghana
| | - Ellen Moseholm
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Åse Bengård Andersen
- Department of Infectious Diseases, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ernest Kenu
- Department of Epidemiology and Disease Control, University of Ghana, Accra, Ghana
| | - Margaret Lartey
- Department of Medicine and Therapeutics, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Isik Somuncu Johansen
- Research Center of Infectious Diseases, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Mycobacterial Centre for Research Southern Denmark, MyCRESD, Department of Infectious Diseases, Odense University Hospital Odense, Odense, Denmark
| | - Stephanie Bjerrum
- Research Center of Infectious Diseases, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Lissouba P, Rücker SCM, Otieno LA, Akatukwasa C, Xulu S, Monjane C, Akinyi M, Okal B, Lubega AV, Stewart R, Bossard C, Ohler L, Antabak NT, Musoke M, Muyindike W, Huerga H. Experiences and perceptions of urine sampling for tuberculosis testing among HIV patients: a multisite qualitative descriptive study. BMJ Open 2023; 13:e058805. [PMID: 38035738 PMCID: PMC10689410 DOI: 10.1136/bmjopen-2021-058805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 10/27/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES Evidence on the acceptability of urine-based assays for tuberculosis (TB) diagnosis among patients remains limited. We sought to describe patients' experiences and perceptions of urine sampling for TB testing at point of care. SETTING Study sites in Kenya, Uganda, Mozambique and South Africa. PARTICIPANTS Adult ambulatory HIV patients enrolled in a TB diagnostic study were selected purposively. INTERVENTION For this qualitative descriptive study, audiorecorded individual interviews conducted with consenting participants were translated, transcribed and analysed using content analysis. Ethical agreement was obtained from relevant ethical review committees. RESULTS Fifty-eight participants were interviewed. Three domains were identified. Overall, participants described urine sampling as easy, rapid and painless, with the main challenge being lacking the urge. Urine was preferred to sputum sampling in terms of simplicity, comfort, stigma reduction, convenience and practicality. While perceptions regarding its trustworthiness for TB diagnosis differed, urine sampling was viewed as an additional mean to detect TB and beneficial for early diagnosis. Participants were willing to wait for several hours for same-day results to allay the emotional, physical and financial burden of having to return to collect results, and would rather not pay for the test. Facilitators of urine sampling included cleanliness and perceived privacy of sampling environments, comprehensive sampling instructions and test information, as well as supplies such as toilet paper and envelopes ensuring confort and privacy when producing and returning samples. Participants motivation for accepting urine-based TB testing stemmed from their perceived susceptibility to TB, the value they attributed to their health, especially when experiencing symptoms, and their positive interactions with the medical team. CONCLUSIONS This study suggests that urine sampling is well accepted as a TB diagnostic method and provides insights on how to promote patients' uptake of urine-based testing and improve their sampling experiences. These results encourage the future broad use of urine-based assays at point of care.
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Affiliation(s)
- Pascale Lissouba
- Field Epidemiology and Training Department, Epicentre, Paris, France
| | | | - Lucy Atieno Otieno
- Médecins Sans Frontières, Homa Bay, Kenya
- Center for Global Health Research, KEMRI, Kisumu, Kenya
| | | | - Sibongiseni Xulu
- Médecins Sans Frontières, Eshowe, South Africa
- Africa Health Research Institute (AHRI), Somkhele, South Africa
- School of Psychology, University of Kwa-Zulu Natal (UKZN), Durban, South Africa
| | | | | | - Beryl Okal
- Médecins Sans Frontières, Homa Bay, Kenya
| | | | | | - Claire Bossard
- Field Epidemiology and Training Department, Epicentre, Paris, France
| | | | | | | | - Winnie Muyindike
- Epicentre, Mbarara, Uganda
- Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- Mbarara Regional Referral Hospital (MRRH), Mbarara, Uganda
| | - Helena Huerga
- Field Epidemiology and Training Department, Epicentre, Paris, France
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Åhsberg J, Puplampu P, Kwashie A, Commey JO, Ganu VJ, Omari MA, Adusi-Poku Y, Andersen ÅB, Kenu E, Lartey M, Johansen IS, Bjerrum S. Point-of-Care Urine Lipoarabinomannan Testing to Guide Tuberculosis Treatment Among Severely Ill Inpatients With Human Immunodeficiency Virus in Real-World Practice: A Multicenter Stepped Wedge Cluster-Randomized Trial From Ghana. Clin Infect Dis 2023; 77:1185-1193. [PMID: 37233720 DOI: 10.1093/cid/ciad316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND The lateral flow urine lipoarabinomannan assay, Determine TB LAM (Determine LAM), offers the potential for timely tuberculosis (TB) treatment among people with human immunodeficiency virus (PWH). METHODS In this cluster-randomized trial, Determine LAM was made available with staff training with performance feedback at 3 hospitals in Ghana. Newly admitted PWH with a positive World Health Organization four-symptom screening for TB, severe illness, or advanced HIV were enrolled. The primary outcome was days from enrollment to TB treatment initiation. We also reported the proportion of patients with a TB diagnosis, initiating TB treatment, all-cause mortality, and Determine LAM uptake at 8 weeks. RESULTS We enrolled 422 patients including 174 (41.2%) in the intervention group. The median CD4 count was 87 (interquartile range [IQR], 25-205) cells/μL, and 32.7% were on antiretroviral therapy. More patients were diagnosed with TB in the intervention compared with the control group: 59 (34.1%) versus 46 (18.7%) (P < .001). Time to TB treatment remained constant, but patients were more likely to initiate TB treatment (adjusted hazard ratio, 2.19 [95% CI, 1.60-3.00]) during the intervention. Of patients with a Determine LAM test available, 41 (25.3%) tested positive. Of those, 19 (46.3%) initiated TB treatment. Overall, 118 patients had died (28.2%) at 8 weeks of follow-up. CONCLUSIONS The Determine LAM intervention in real-world practice increased TB diagnosis and the probability of TB treatment but did not reduce time to treatment initiation. Despite high uptake, only half of the LAM-positive patients initiated TB treatment.
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Affiliation(s)
- Johanna Åhsberg
- Research Center of Infectious Diseases, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Mycobacterial Centre for Research Southern Denmark, Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Peter Puplampu
- Department of Medicine & Therapeutics, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | | | - Joseph Oliver Commey
- Department of Medicine, Lekma Hospital, Teshie, Ghana
- Department of Clinical Infectious Diseases, Ghana Infectious Disease Centre, Accra, Ghana
| | | | - Michael Amo Omari
- Department of Chest Diseases, Korle Bu Teaching Hospital, Korle Bu, Ghana; and
| | - Yaw Adusi-Poku
- National Tuberculosis Control Programme, Ghana Health Service, Korle Bu, Ghana
| | - Åse Bengård Andersen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ernest Kenu
- Department of Epidemiology and Disease Control, University of Ghana, Accra, Ghana
| | - Margaret Lartey
- Department of Medicine & Therapeutics, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Isik Somuncu Johansen
- Research Center of Infectious Diseases, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Mycobacterial Centre for Research Southern Denmark, Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Stephanie Bjerrum
- Research Center of Infectious Diseases, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Mycobacterial Centre for Research Southern Denmark, Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Aguiar Soares K, Ehrlich J, Camará M, Chaloub S, Emeka E, Gando HG, Ismail F, Mvusi L, Jele T, José B, Kgwaadira B, Kisonga R, Letta T, Liega AO, Lungu PS, Maama L, Mahoumbou J, Mbendera K, Ogoro J, Tollo DAD, Sandy C, Saye RG, Sheehama J, Musala S, Tugumisirize D, Carratala L, Cossa M, Garcia-Basteiro AL. Implementation of WHO guidelines on urine lateral flow LAM testing in high TB/HIV burden African countries. Eur Respir J 2023; 62:2300556. [PMID: 37802630 DOI: 10.1183/13993003.00556-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/26/2023] [Indexed: 10/10/2023]
Affiliation(s)
| | - Joanna Ehrlich
- ISGlobal - Barcelona Institute for Global Health, Barcelona, Spain
| | - Miguel Camará
- Programa Nacional de Luta Contra Lepra e Tuberculose, Bissau, Guinea-Bissau
| | | | - Elom Emeka
- National Tuberculosis and Leprosy Control Programme, Abuja, Nigeria
| | - Hervé Gildas Gando
- Service de Lutte Contre la Tuberculose, Bangui, Central African Republic
| | - Farzana Ismail
- Centre for Tuberculosis, National Institute for Communicable Diseases/National Health Laboratory Services, Johannesburg, South Africa
| | - Lindiwe Mvusi
- TB Control and Management, National Department of Health, Pretoria, South Africa
| | - Thulani Jele
- National Tuberculosis Control Programme, Manzini, Eswatini
| | - Benedita José
- Programa Nacional de Controlo da Tuberculose, Maputo, Mozambique
| | | | - Riziki Kisonga
- National Tuberculosis and Leprosy Programme, Dar Es Salaam, United Republic of Tanzania
| | - Taye Letta
- National Tuberculosis and Leprosy Programme, Addis Ababa, Ethiopia
| | | | | | - Llang Maama
- National Tuberculosis and Leprosy Programme, Maseru, Lesotho
| | - Jocelyn Mahoumbou
- Programme National de Lutte Contre la Tuberculose, Libreville, Gabon
| | | | - Jeremiah Ogoro
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | | | | | - Rufus G Saye
- National Leprosy and Tuberculosis Control Programme, Monrovia, Liberia
| | | | - Sissy Musala
- Programme National de Lutte Contre la Tuberculose, Kinshasa, Democratic Republic of the Congo
| | - Didas Tugumisirize
- Ministry of Health - National Tuberculosis Reference Laboratory, Kampala, Uganda
| | - Lucia Carratala
- ISGlobal - Barcelona Institute for Global Health, Barcelona, Spain
| | - Marta Cossa
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
| | - Alberto L Garcia-Basteiro
- ISGlobal - Barcelona Institute for Global Health, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
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Wilson D, Cudahy P, Drain PK. Urine and sputum tuberculosis tests: defining the trade-offs in endemic HIV and tuberculosis settings. Lancet Glob Health 2023; 11:e809-e810. [PMID: 37202010 DOI: 10.1016/s2214-109x(23)00215-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/26/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Douglas Wilson
- Department of Internal Medicine, Harry Gwala Regional Hospital, University of KwaZulu-Natal, Pietermaritzburg 3216, South Africa.
| | - Patrick Cudahy
- Division of Infectious Diseases, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Paul K Drain
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
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Broger T, Koeppel L, Huerga H, Miller P, Gupta-Wright A, Blanc FX, Esmail A, Reeve BWP, Floridia M, Kerkhoff AD, Ciccacci F, Kasaro MP, Thit SS, Bastard M, Ferlazzo G, Yoon C, Van Hoving DJ, Sossen B, García JI, Cummings MJ, Wake RM, Hanson J, Cattamanchi A, Meintjes G, Maartens G, Wood R, Theron G, Dheda K, Olaru ID, Denkinger CM. Diagnostic yield of urine lipoarabinomannan and sputum tuberculosis tests in people living with HIV: a systematic review and meta-analysis of individual participant data. Lancet Glob Health 2023; 11:e903-e916. [PMID: 37202025 DOI: 10.1016/s2214-109x(23)00135-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/19/2023] [Accepted: 02/27/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Sputum is the most widely used sample to diagnose active tuberculosis, but many people living with HIV are unable to produce sputum. Urine, in contrast, is readily available. We hypothesised that sample availability influences the diagnostic yield of various tuberculosis tests. METHODS In this systematic review and meta-analysis of individual participant data, we compared the diagnostic yield of point-of-care urine-based lipoarabinomannan tests with that of sputum-based nucleic acid amplification tests (NAATs) and sputum smear microscopy (SSM). We used microbiologically confirmed tuberculosis based on positive culture or NAAT from any body site as the denominator and accounted for sample provision. We searched PubMed, Web of Science, Embase, African Journals Online, and clinicaltrials.gov from database inception to Feb 24, 2022 for randomised controlled trials, cross-sectional studies, and cohort studies that assessed urine lipoarabinomannan point-of-care tests and sputum NAATs for active tuberculosis detection in participants irrespective of tuberculosis symptoms, HIV status, CD4 cell count, or study setting. We excluded studies in which recruitment was not consecutive, systematic, or random; provision of sputum or urine was an inclusion criterion; less than 30 participants were diagnosed with tuberculosis; early research assays without clearly defined cutoffs were tested; and humans were not studied. We extracted study-level data, and authors of eligible studies were invited to contribute deidentified individual participant data. The main outcomes were the tuberculosis diagnostic yields of urine lipoarabinomannan tests, sputum NAATs, and SSM. Diagnostic yields were predicted using Bayesian random-effects and mixed-effects meta-analyses. This study is registered with PROSPERO, CRD42021230337. FINDINGS We identified 844 records, from which 20 datasets and 10 202 participants (4561 [45%] male participants and 5641 [55%] female participants) were included in the meta-analysis. All studies assessed sputum Xpert (MTB/RIF or Ultra, Cepheid, Sunnyvale, CA, USA) and urine Alere Determine TB LAM (AlereLAM, Abbott, Chicago, IL, USA) in people living with HIV aged 15 years or older. Nearly all (9957 [98%] of 10 202) participants provided urine, and 82% (8360 of 10 202) provided sputum within 2 days. In studies that enrolled unselected inpatients irrespective of tuberculosis symptoms, only 54% (1084 of 1993) of participants provided sputum, whereas 99% (1966 of 1993) provided urine. Diagnostic yield was 41% (95% credible interval [CrI] 15-66) for AlereLAM, 61% (95% Crl 25-88) for Xpert, and 32% (95% Crl 10-55) for SSM. Heterogeneity existed across studies in the diagnostic yield, influenced by CD4 cell count, tuberculosis symptoms, and clinical setting. In predefined subgroup analyses, all tests had higher yields in symptomatic participants, and AlereLAM yield was higher in those with low CD4 counts and inpatients. AlereLAM and Xpert yields were similar among inpatients in studies enrolling unselected participants who were not assessed for tuberculosis symptoms (51% vs 47%). AlereLAM and Xpert together had a yield of 71% in unselected inpatients, supporting the implementation of combined testing strategies. INTERPRETATION AlereLAM, with its rapid turnaround time and simplicity, should be prioritised to inform tuberculosis therapy among inpatients who are HIV-positive, regardless of symptoms or CD4 cell count. The yield of sputum-based tuberculosis tests is undermined by people living with HIV who cannot produce sputum, whereas nearly all participants are able to provide urine. The strengths of this meta-analysis are its large size, the carefully harmonised denominator, and the use of Bayesian random-effects and mixed-effects models to predict yields; however, data were geographically restricted, clinically diagnosed tuberculosis was not considered in the denominator, and little information exists on strategies for obtaining sputum samples. FUNDING FIND, the Global Alliance for Diagnostics.
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Affiliation(s)
- Tobias Broger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Lisa Koeppel
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | - Poppy Miller
- New Zealand Institute for Plant and Food Research, Auckland, New Zealand
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - François-Xavier Blanc
- Service de Pneumologie, l'institut du thorax, Nantes Université, CHU Nantes, Nantes, France
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa; South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Byron W P Reeve
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Trauma Center, University of California San Francisco, San Francisco, CA, USA; Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Fausto Ciccacci
- UniCamillus, International University of Health and Medical Science, Rome, Italy; Community of Sant'Egidio, DREAM programme, Rome, Italy
| | - Margaret P Kasaro
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; UNC Global Projects, LLC Zambia, Lusaka, Zambia
| | - Swe Swe Thit
- Department of Medicine, University of Medicine 2, Yangon, Myanmar
| | | | | | - Christina Yoon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Daniël J Van Hoving
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa; Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | - Bianca Sossen
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Juan Ignacio García
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY, USA; Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rachel M Wake
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa; Institute for Infection and Immunity, St George's University of London, London, UK
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Adithya Cattamanchi
- Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, CA, USA
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Keertan Dheda
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK; Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa; South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Ioana Diana Olaru
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; German Center for Infection Research, partner site, Heidelberg University Hospital, Heidelberg, Germany.
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7
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Huerga H, Gupta-Wright A, Muyindike W, Hewison C, Casenghi M, Bonnet M. Lots of considerations when evaluating the FujiLAM assay - Author's reply. Lancet Glob Health 2023; 11:e502. [PMID: 36925168 DOI: 10.1016/s2214-109x(23)00115-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Helena Huerga
- Department of Field Epidemiology, Epicentre, Paris 75019, France.
| | | | - Winnie Muyindike
- Department of Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | | | - Martina Casenghi
- Department of Innovation and New Technology, Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - Maryline Bonnet
- Université de Montpellier, TransVIHMI, INSERM, IRD, Montpellier, France
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8
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Oboho IK, Paulin H, Corcoran C, Hamilton M, Jordan A, Kirking HL, Agyemang E, Podewils LJ, Pretorius C, Greene G, Chiller T, Desai M, Bhatkoti R, Shiraishi RW, Shah NS. Modelling the impact of CD4 testing on mortality from TB and cryptococcal meningitis among patients with advanced HIV disease in nine countries. J Int AIDS Soc 2023; 26:e26070. [PMID: 36880429 PMCID: PMC9989935 DOI: 10.1002/jia2.26070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 02/10/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Despite antiretroviral therapy (ART) scale-up among people living with HIV (PLHIV), those with advanced HIV disease (AHD) (defined in adults as CD4 count <200 cells/mm3 or clinical stage 3 or 4), remain at high risk of death from opportunistic infections. The shift from routine baseline CD4 testing towards viral load testing in conjunction with "Test and Treat" has limited AHD identification. METHODS We used official estimates and existing epidemiological data to project deaths from tuberculosis (TB) and cryptococcal meningitis (CM) among PLHIV-initiating ART with CD4 <200 cells/mm3 , in the absence of select World Health Organization recommended diagnostic or therapeutic protocols for patients with AHD. We modelled the reduction in deaths, based on the performance of screening/diagnostic testing and the coverage and efficacy of treatment/preventive therapies for TB and CM. We compared projected TB and CM deaths in the first year of ART from 2019 to 2024, with and without CD4 testing. The analysis was performed for nine countries: South Africa, Kenya, Lesotho, Mozambique, Nigeria, Uganda, Zambia, Zimbabwe and the Democratic Republic of Congo. RESULTS The effect of CD4 testing comes through increased identification of AHD and consequent eligibility for protocols for AHD prevention, diagnosis and management; algorithms for CD4 testing avert between 31% and 38% of deaths from TB and CM in the first year of ART. The number of CD4 tests required per death averted varies widely by country from approximately 101 for South Africa to 917 for Kenya. CONCLUSIONS This analysis supports retaining baseline CD4 testing to avert deaths from TB and CM, the two most deadly opportunistic infections among patients with AHD. However, national programmes will need to weigh the cost of increasing CD4 access against other HIV-related priorities and allocate resources accordingly.
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Affiliation(s)
- Ikwo Kitefre Oboho
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Heather Paulin
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Carl Corcoran
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | | | - Alex Jordan
- Division of FoodborneWaterborne and Environmental DiseasesCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Hannah L. Kirking
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Elfriede Agyemang
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Laura Jean Podewils
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
- Denver Health and Hospital AuthorityDenverColoradoUSA
| | | | - Greg Greene
- Division of FoodborneWaterborne and Environmental DiseasesCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Tom Chiller
- Division of FoodborneWaterborne and Environmental DiseasesCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Mitesh Desai
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
- U.S. Office of Global AIDS Coordinator and Health DiplomacyWashingtonDCUSA
| | - Roma Bhatkoti
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Ray W. Shiraishi
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - N. Sarita Shah
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
- Emory Rollins School of Public HealthAtlantaGeorgiaUSA
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Mapamba DA, Sauli E, Lalashowi J, Buza J, John J, Mwaisango Z, Tarmo P, Sabi I, Rachow A, Ntinginya NE, Mtafya B. Performance of Tuberculosis Molecular Bacterial Load Assay Compared to Alere TB-LAM in Urine of Pulmonary Tuberculosis Patients with HIV Co-Infections. Int J Mol Sci 2023; 24:ijms24043715. [PMID: 36835127 PMCID: PMC9965206 DOI: 10.3390/ijms24043715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/20/2023] [Accepted: 02/03/2023] [Indexed: 02/17/2023] Open
Abstract
Alternative tools are needed to improve the detection of M. tuberculosis (M. tb) in HIV co-infections. We evaluated the utility of Tuberculosis Molecular Bacterial Load Assay (TB-MBLA) compared to lipoarabinomannan (LAM) to detect M. tb in urine. Sputum Xpert MTB/RIF-positive patients were consented to provide urine at baseline, weeks 2, 8, 16, and 24 of treatment for TB-MBLA, culture, and LAM. Results were compared with sputum cultures and microscopy. Initial M. tb. H37Rv spiking experiments were performed to validate the tests. A total of 63 urine samples from 47 patients were analyzed. The median age (IQR) was 38 (30-41) years; 25 (53.2%) were male, 3 (6.5%) had urine for all visits, 45 (95.7%) were HIV positive, of whom 18 (40%) had CD4 cell counts below 200 cells/µL, and 33 (73.3%) were on ART at enrollment. Overall urine LAM positivity was 14.3% compared to 4.8% with TB-MBLA. Culture and microscopy of their sputum counterparts were positive in 20.6% and 12.7% of patients, respectively. Of the three patients with urine and sputum at baseline, one (33.33%) had urine TB-MBLA and LAM positive compared to 100% with sputum MGIT culture positive. Spearman's rank correction coefficient (r) between TB-MBLA and MGIT was -0.85 and 0.89 with a solid culture, p > 0.05. TB-MBLA has the promising potential to improve M. tb detection in urine of HIV-co-infected patients and complement current TB diagnostics.
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Affiliation(s)
- Daniel Adon Mapamba
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
- The Nelson Mandela African Institution of Science and Technology, Arusha P.O. Box 447, Tanzania
- Correspondence: ; Tel.: +255-25-250-3364
| | - Elingarami Sauli
- The Nelson Mandela African Institution of Science and Technology, Arusha P.O. Box 447, Tanzania
| | - Julieth Lalashowi
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Joram Buza
- The Nelson Mandela African Institution of Science and Technology, Arusha P.O. Box 447, Tanzania
| | - Joseph John
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Zawadi Mwaisango
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Peter Tarmo
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Issa Sabi
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Andrea Rachow
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), 80802 Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, 81675 Munich, Germany
| | - Nyanda Elias Ntinginya
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Bariki Mtafya
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
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10
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Huerga H, Bastard M, Lubega AV, Akinyi M, Antabak NT, Ohler L, Muyindike W, Taremwa IM, Stewart R, Bossard C, Nkosi N, Ndlovu Z, Hewison C, Stavia T, Okomo G, Ogoro JO, Ngozo J, Mbatha M, Aleny C, Wanjala S, Musoke M, Atwine D, Ascorra A, Ardizzoni E, Casenghi M, Ferlazzo G, Nakiyingi L, Gupta-Wright A, Bonnet M. Novel FujiLAM assay to detect tuberculosis in HIV-positive ambulatory patients in four African countries: a diagnostic accuracy study. Lancet Glob Health 2023; 11:e126-e135. [PMID: 36521944 PMCID: PMC9747168 DOI: 10.1016/s2214-109x(22)00463-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Development of rapid biomarker-based tests that can diagnose tuberculosis using non-sputum samples is a priority for tuberculosis control. We aimed to compare the diagnostic accuracy of the novel Fujifilm SILVAMP TB LAM (FujiLAM) assay with the WHO-recommended Alere Determine TB-LAM Ag test (AlereLAM) using urine samples from HIV-positive patients. METHODS We did a diagnostic accuracy study at five outpatient public health facilities in Uganda, Kenya, Mozambique, and South Africa. Eligible patients were ambulatory HIV-positive individuals (aged ≥15 years) with symptoms of tuberculosis irrespective of their CD4 T-cell count (group 1), and asymptomatic patients with advanced HIV disease (CD4 count <200 cells per μL, or HIV clinical stage 3 or 4; group 2). All participants underwent clinical examination, chest x-ray, and blood sampling, and were requested to provide a fresh urine sample, and two sputum samples. FujiLAM and AlereLAM urine assays, Xpert MTB/RIF Ultra assay on sputum or urine, sputum culture for Mycobacterium tuberculosis, and CD4 count were systematically carried out for all patients. Sensitivity and specificity of FujiLAM and AlereLAM were evaluated against microbiological and composite reference standards. FINDINGS Between Aug 24, 2020 and Sept 21, 2021, 1575 patients (823 [52·3%] women) were included in the study: 1031 patients in group 1 and 544 patients in group 2. Tuberculosis was microbiologically confirmed in 96 (9·4%) of 1022 patients in group 1 and 18 (3·3%) of 542 patients in group 2. Using the microbiological reference standard, FujiLAM sensitivity was 60% (95% CI 51-69) and AlereLAM sensitivity was 40% (31-49; p<0·001). Among patients with CD4 counts of less than 200 cells per μL, FujiLAM sensitivity was 69% (57-79) and AlereLAM sensitivity was 52% (40-64; p=0·0218). Among patients with CD4 counts of 200 cells per μL or higher, FujiLAM sensitivity was 47% (34-61) and AlereLAM sensitivity was 24% (14-38; p=0·0116). Using the microbiological reference standard, FujiLAM specificity was 87% (95% CI 85-89) and AlereLAM specificity was 86% (95 CI 84-88; p=0·941). FujiLAM sensitivity varied by lot number from 48% (34-62) to 76% (57-89) and specificity from 77% (72-81) to 98% (93-99). INTERPRETATION Next-generation, higher sensitivity urine-lipoarabinomannan assays are potentially promising tests that allow rapid tuberculosis diagnosis at the point of care for HIV-positive patients. However, the variability in accuracy between FujiLAM lot numbers needs to be addressed before clinical use. FUNDING ANRS and Médecins Sans Frontières.
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Affiliation(s)
- Helena Huerga
- Department of Field Epidemiology, Epicentre, Paris, France.
| | | | | | - Milcah Akinyi
- Department of Medicine, Médecins Sans Frontières, Nairobi, Kenya
| | | | - Liesbet Ohler
- Department of Medicine, Médecins Sans Frontières, Eshowe, South Africa
| | - Winnie Muyindike
- Department of Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | | | - Rosanna Stewart
- Department of Medicine, Médecins Sans Frontières, Eshowe, South Africa
| | - Claire Bossard
- Department of Field Epidemiology, Epicentre, Paris, France
| | - Nothando Nkosi
- Department of Medicine, Médecins Sans Frontières, Eshowe, South Africa
| | - Zibusiso Ndlovu
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | - Turyahabwe Stavia
- National Tuberculosis and Leprosy Control Services, Ministry of Health, Kampala, Uganda
| | - Gordon Okomo
- Department of Health Services, Ministry of Health, Homa Bay, Kenya
| | - Jeremiah Okari Ogoro
- National Tuberculosis and Leprosy Control Services, Ministry of Health, Nairobi, Kenya
| | | | - Mduduzi Mbatha
- King Cetswayo District Office, Department of Health, Eshowe, South Africa
| | - Couto Aleny
- National STI, HIV/AIDS Control Program, Ministry of Health, Maputo, Mozambique
| | - Stephen Wanjala
- Department of Medicine, Médecins Sans Frontières, Nairobi, Kenya
| | - Mohammed Musoke
- Department of Medicine, Médecins Sans Frontières, Nairobi, Kenya
| | | | | | - Elisa Ardizzoni
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Martina Casenghi
- Department of Innovation and New Technology, Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - Gabriella Ferlazzo
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Lydia Nakiyingi
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Maryline Bonnet
- Université de Montpellier, TransVIHMI, INSERM, IRD, Montpellier, France
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11
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Saluja K, Reddy KS, Wang Q, Zhu Y, Li Y, Chu X, Li R, Hou L, Horsley T, Carden F, Bartolomeos K, Hatcher Roberts J. Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review. Health Res Policy Syst 2022; 20:98. [PMID: 36071468 PMCID: PMC9449928 DOI: 10.1186/s12961-022-00899-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/16/2022] [Indexed: 11/20/2022] Open
Abstract
Background WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO’s Thirteenth General Programme of Work for 2019–2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship. Methods We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.
Results The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States’ health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO’s guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines. Conclusions The challenges identified reflect the national health systems’ (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-022-00899-y.
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Affiliation(s)
- Kiran Saluja
- Bruyere Research Institute, Ottawa, Canada.,Science Division, World Health Organization, Geneva, Switzerland
| | - K Srikanth Reddy
- Bruyere Research Institute, Ottawa, Canada. .,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada. .,Using Evidence Inc., Ottawa, Canada. .,Science Division, World Health Organization, Geneva, Switzerland.
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Ying Zhu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Yanfei Li
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xiajing Chu
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Rui Li
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liangying Hou
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Tanya Horsley
- Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
| | | | | | - Janet Hatcher Roberts
- WHO Collaborating Centre for Knowledge Translation and Health Impact Assessment in Health Equity, Bruyere Research Institute, University of Ottawa, Ottawa, Canada
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12
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Kraef C, Lindquist E, Svensson E, Cambau E. Diagnostic toolkit for tuberculosis: should we include urine lipoarabinomannan (LAM) detection in the WHO European Region? Clin Microbiol Infect 2022; 28:1406-1408. [PMID: 35798147 DOI: 10.1016/j.cmi.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/12/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Christian Kraef
- Centre of Excellence for Health, Immunity and Infections & Departmant of Infectious Diseases, Rigshospitalet, University of Copenhagen, Denmark.
| | - Emilia Lindquist
- European Centre for Disease Prevention and Control, Gustav III:s Boulevard 40, 169 73 Stockholm, Sweden
| | - Erik Svensson
- International Reference Laboratory of Mycobacteriology, Statens Seum Institut, Artillerivej 5, DK-2300 Copenhagen S, Denmark
| | - Emmanuelle Cambau
- Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP, GHU Nord, service de Mycobactériologie spécialisée et de référence, laboratoire associé au Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, F-75018 Paris, France.
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13
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Gupta-Wright A. Tuberculosis diagnostics to reduce HIV-associated mortality. CLINICAL INFECTION IN PRACTICE 2022. [DOI: 10.1016/j.clinpr.2022.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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14
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Dhana A, Hamada Y, Kengne AP, Kerkhoff AD, Broger T, Denkinger CM, Rangaka MX, Gupta-Wright A, Fielding K, Wood R, Huerga H, Rücker SCM, Bjerrum S, Johansen IS, Thit SS, Kyi MM, Hanson J, Barr DA, Meintjes G, Maartens G. Diagnostic accuracy of WHO screening criteria to guide lateral-flow lipoarabinomannan testing among HIV-positive inpatients: A systematic review and individual participant data meta-analysis. J Infect 2022; 85:40-48. [PMID: 35588942 PMCID: PMC10152564 DOI: 10.1016/j.jinf.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND WHO recommends urine lateral-flow lipoarabinomannan (LF-LAM) testing with AlereLAM in HIV-positive inpatients only if screening criteria are met. We assessed the performance of WHO screening criteria and alternative screening tests/strategies to guide LF-LAM testing and compared diagnostic accuracy of the WHO AlereLAM algorithm (WHO screening criteria followed by AlereLAM if screen positive) with AlereLAM and FujiLAM (a novel LF-LAM test) testing in all HIV-positive inpatients. METHODS We searched MEDLINE, Embase, and Cochrane Library from Jan 1, 2011 to March 1, 2020 for studies among adult/adolescent HIV-positive inpatients regardless of tuberculosis signs and symptoms. The reference standards were (1) AlereLAM or FujiLAM for screening tests/strategies and (2) culture or Xpert for AlereLAM/FujiLAM. We determined proportion of inpatients eligible for AlereLAM using WHO screening criteria; assessed accuracy of WHO criteria and alternative screening tests/strategies to guide LF-LAM testing; compared accuracy of WHO AlereLAM algorithm with AlereLAM/FujiLAM testing in all; and determined diagnostic yield of AlereLAM, FujiLAM, and Xpert MTB/RIF (Xpert). We estimated pooled proportions with a random-effects model, assessed diagnostic accuracy using random-effects bivariate models, and assessed diagnostic yield descriptively. FINDINGS We obtained data from all 5 identified studies (n = 3,504). The pooled proportion of inpatients eligible for AlereLAM using WHO criteria was 93% (95%CI 91, 95). Among screening tests/strategies to guide LF-LAM testing, WHO criteria, C-reactive protein (≥5 mg/L), and CD4 count (<200 cells/μL) had high sensitivities but low specificities; cough (≥2 weeks), hemoglobin (<8 g/dL), body mass index (<18.5 kg/m2), lymphadenopathy, and WHO-defined danger signs had higher specificities but suboptimal sensitivities. AlereLAM in all had the same sensitivity (62%) and specificity (88%) as WHO AlereLAM algorithm. Sensitivity of FujiLAM and AlereLAM was 69% and 48%, while specificity was 88% and 96%, respectively. In 2 studies that collected sputum and non-sputum samples for Xpert and/or culture, diagnostic yield of sputum Xpert was 40-41%, AlereLAM was 39-76%, and urine Xpert was 35-62%. In one study, FujiLAM diagnosed 80% of tuberculosis cases (vs 39% for AlereLAM), and sputum Xpert combined with AlereLAM, urine Xpert, or FujiLAM diagnosed 61%, 81%, and 92% of all cases, respectively. INTERPRETATION WHO criteria and alternative screening tests/strategies have limited utility in guiding LF-LAM testing, suggesting that AlereLAM testing in all HIV-positive medical inpatients be implemented. Routine FujiLAM may improve tuberculosis diagnosis. FUNDING None.
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Affiliation(s)
- Ashar Dhana
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yohhei Hamada
- Centre for International Cooperation and Global TB Information, The Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan; Institute for Global Health, University College London, London, UK
| | - Andre P Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| | - Tobias Broger
- Division of Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany; FIND, Geneva, Switzerland
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany; German Center of Infection Research, Heidelberg, Germany; FIND, Geneva, Switzerland
| | - Molebogeng X Rangaka
- Institute for Global Health, University College London, London, UK; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | | | - Stephanie Bjerrum
- Department of Clinical Research, Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Isik S Johansen
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Swe Swe Thit
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - David A Barr
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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15
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Wake RM, Govender NP, Omar SV, Ismail F, Tiemessen CT, Harrison TS, Jarvis JN. Rapid urine-based screening tests increase the yield of same-day tuberculosis diagnoses among patients living with advanced HIV disease. AIDS 2022; 36:839-844. [PMID: 35075041 PMCID: PMC11382303 DOI: 10.1097/qad.0000000000003177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Investigation of the diagnostic yield of urine-based tuberculosis (TB) screening in patients with advanced HIV disease. DESIGN A cross-sectional screening study. SETTING HIV outpatient clinics and wards at two hospitals in Johannesburg, South Africa, between June 2015 and October 2017. PARTICIPANTS Two hundred and one patients living with advanced HIV disease (CD4+ T-lymphocytes <100 cells/μl) attending healthcare facilities following cryptococcal antigen (CrAg) screening. INTERVENTION Screening for TB using sputum for microscopy, culture, and Xpert MTB/Rif and urine for lipoarabinomannan (LAM) and Xpert Ultra. MAIN OUTCOME MEASURES Proportion of positive results using each testing modality, sensitivity, and specificity of urine-based testing compared with culture, and survival outcomes during 6 months follow up. RESULTS Urine was obtained from 177 of 181 (98%) participants and sputum from 91 (50%). Urine-based screening increased same-day diagnostic yield from 7 (4%) to 31 (17%). A positive urine test with either LAM or Xpert Ultra had 100% sensitivity (95% confidence interval, 59-100%) for detecting culture-positive TB at any site. Patients with newly diagnosed TB on urine-based screening were initiated on treatment and did not have excess mortality compared with the remainder of the cohort. CONCLUSION Urine is an easily obtainable sample with utility for detecting TB in patients with advanced HIV disease. Combining urine and sputum-based screening in this population facilitates additional same-day TB diagnoses and early treatment initiation, potentially reducing the risk of TB-related mortality. Urine-based as well as sputum-based screening for TB should be integrated with CrAg screening in patients living with advanced HIV disease.
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Affiliation(s)
- Rachel M Wake
- Institute for Infection and Immunity, St George's University of London
- Clinical Academic Group in Infection and Immunity, St George's University Hospital NHS Foundation Trust, London, UK
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses (CHARM), National Institute for Communicable Diseases, a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Nelesh P Govender
- Institute for Infection and Immunity, St George's University of London
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses (CHARM), National Institute for Communicable Diseases, a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
- Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand
- Division of Medical Microbiology, University of Cape Town, Cape Town
| | - Shaheed V Omar
- Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand
- Department of Medical Microbiology, University of Pretoria, Pretoria
- Centre for Tuberculosis
| | - Farzana Ismail
- Department of Medical Microbiology, University of Pretoria, Pretoria
- Centre for Tuberculosis
| | - Caroline T Tiemessen
- Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand
- Centre for HIV & STIs, National Institute for Communicable Diseases, a Division of the NHLS, Johannesburg, South Africa
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George's University of London
- Clinical Academic Group in Infection and Immunity, St George's University Hospital NHS Foundation Trust, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gabarone, Botswana
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16
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Nel J, Gupta-Wright A. Urine tuberculosis diagnostics in patients with advanced HIV. AIDS 2022; 36:897-898. [PMID: 35506266 DOI: 10.1097/qad.0000000000003178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jeremy Nel
- University of the Witwatersrand, Johannesburg, South Africa
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London UK
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17
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Chenai Mathabire Rücker S, Lissouba P, Akinyi M, Vicent Lubega A, Stewart R, Tamayo Antabak N, Taremwa Mugisha I, Ohler L, Macuácua H, Atieno M, Muyindike W, Turyahabwe S, Odhiambo Okomo G, Mahomed Couto A, Musoke M, Bossard C, Hewison C, Ndlovu Z, Huerga H. Feasibility and acceptability of using the novel urine-based FujiLAM test to detect tuberculosis: a multi-country mixed-methods study. J Clin Tuberc Other Mycobact Dis 2022; 27:100316. [PMID: 35521634 PMCID: PMC9065638 DOI: 10.1016/j.jctube.2022.100316] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
FujiLAM is feasible to implement at point-of-care using existing infrastructure. FujiLAM can be performed in laboratory and consultation or other spaces. FujiLAM adequately performed by any health worker including lay health workers. FujiLAM well accepted by users and managers, perceived as easy to perform. Selection of users should consider expected test demand and existing user workload.
Background The novel urine-based FujiLAM test identifies tuberculosis in HIV-positive patients but may be challenging to use at point-of-care (POC). Objectives We assessed the feasibility and acceptability of using the FujiLAM test at point of care in outpatient settings. Methods We conducted a mixed methods study in four outpatient settings in Kenya, Mozambique, South Africa, and Uganda between November 2020 and September 2021. The test was performed at POC in existing clinic laboratories and consultation spaces. We performed direct observations in the four health facilities, individual questionnaires, proficiency testing evaluations, and individual interviews among healthcare workers performing the FujiLAM test (healthcare workers), and group discussions with programme managers. Results Overall, 18/19 (95%) healthcare workers and 14/14 (100%) managers agreed to participate in the study. Most assessed healthcare workers, including lay health workers (10/11; 91%), met the minimum required theoretical knowledge and practical skill in performing the FujiLAM test. Most healthcare workers (17/18; 94%) found the FujiLAM test overall “Easy/Very easy” to perform. Some challenges were mentioned: many timed steps (5/18; 28%); ensuring correct incubation period (5/18; 28%); test result readability (4/18; 22%); and difficulties with cartridge buttons (3/18; 17%). Half of the healthcare workers regularly performing the test (4/7; 57%) found it “Easy” to integrate into routine activities. Most healthcare workers and managers believed that any healthcare worker could perform the test after adequate training. Conclusions Implementing the FujiLAM test in outpatient POC settings is feasible and acceptable to healthcare workers and managers. This test can be performed in various clinic locations by any healthcare worker. The timed, multi-step test procedure is challenging and may affect the workload in resource-constrained health facilities.
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Gils T, Lynen L, Muhairwe J, Mashaete K, Lejone TI, Joseph P, Ngubane T, Keter AK, Reither K, van Heerden A. Feasibility of implementing the advanced HIV disease care package as part of community-based HIV/TB activities: a mixed-methods study protocol. BMJ Open 2022; 12:e057291. [PMID: 35131835 PMCID: PMC8823294 DOI: 10.1136/bmjopen-2021-057291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Although the advanced HIV disease (AHD) care package reduces morbidity and mortality in people with AHD (defined in people living with HIV as WHO stage 3 or 4, CD4 count <200 cells/µL or age <5 years), it is barely implemented in many countries. A novel point-of-care CD4 test rapidly identifies AHD. We evaluate the feasibility of implementing the AHD care package as part of community-based HIV/tuberculosis services. METHODS AND ANALYSIS This two-phased study is guided by the Medical Research Council framework for evaluation of complex interventions. Stage 1 is a stakeholder consultation to define tools and indicators to assess feasibility of the AHD care package. Stage 2 is the implementation of the AHD care package during a facility-based tuberculosis diagnostic accuracy study in high-burden HIV/tuberculosis settings. Consenting adults with tuberculosis symptoms in two sites in Lesotho and South Africa are eligible for inclusion. HIV-positive participants are included in the feasibility study and are offered a CD4 test, a tuberculosis-lipoarabinomannan assay and those with CD4 count of ≤200 cells/µL a cryptococcal antigen lateral flow assay. Participants are referred for clinical management following national guidelines. The evaluation includes group discussions, participant observation (qualitative strand) and a semistructured questionnaire to assess acceptability among implementers. The quantitative strand also evaluates process compliance (process rating and process cascade) and early outcomes (vital and treatment status after twelve weeks). Thematic content analysis, descriptive statistics and data triangulation will be performed. ETHICS AND DISSEMINATION The National Health Research and Ethics Committee, Lesotho, the Human Sciences Research Council Research Ethics Committee and Provincial Department of Health, South Africa and the Ethikkommission Nordwest- und Zentralschweiz, Switzerland, approved the protocol. Dissemination will happen locally and internationally at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04666311.
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Affiliation(s)
- Tinne Gils
- Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Lutgarde Lynen
- Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Josephine Muhairwe
- SolidarMed, Partnerships for Health, Maseru, Lesotho
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | | | - Philip Joseph
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Thulani Ngubane
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | | | - Klaus Reither
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Medical Outpatient Department, University of Basel, Basel, Switzerland
| | - Alastair van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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Herrmann Y, Lainati F, Castro MDM, Mwamba CP, Kumwenda M, Muyoyeta M, Broger T, Heinrich N, Olbrich L, Corbett EL, McMahon SA, Engel N, Denkinger CM. User perspectives and preferences on a novel TB LAM diagnostic (Fujifilm SILVAMP TB LAM)-a qualitative study in Malawi and Zambia. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000672. [PMID: 36962216 PMCID: PMC10021253 DOI: 10.1371/journal.pgph.0000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
Widely available tuberculosis (TB) diagnostics use sputum samples. However, many patients, particularly children and patients living with HIV (PLHIV), struggle to provide sputum. Urine diagnostics are a promising approach to circumvent this challenge while delivering reliable and timely diagnosis. This qualitative study in two high TB/HIV burden countries assesses values and preferences of end-users, along with potential barriers for the implementation of the novel Fujifilm SILVAMP TB-LAM (FujiLAM, Fujifilm, Japan) urine test. Between September 2020 and March 2021, we conducted 42 semi-structured interviews with patients, health care providers (HCPs) and decision makers (DMs) (e.g., in national TB programs) in Malawi and Zambia. Interviews were transcribed verbatim and analyzed using a framework approach supported by NVIVO. Findings aligned with the pre-existing Health Equity Implementation Framework, which guided the presentation of results. The ease and convenience of urine-based testing was described as empowering among patients and HCPs who lamented the difficulty of sputum collection, however HCPs expressed concerns that a shift in agency to the patient may affect clinic workflows (e.g., due to less control over collection). Implementation facilitators, such as shorter turnaround times, were welcomed by operators and patients alike. The decentralization of diagnostics was considered possible with FujiLAM by HCPs and DMs due to low infrastructure requirements. Finally, our findings support efforts for eliminating the CD4 count as an eligibility criterion for LAM testing, to facilitate implementation and benefit a wider range of patients. Our study identified barriers and facilitators relevant to scale-up of urine LAM tests in Malawi and Zambia. FujiLAM could positively impact health equity, as it would particularly benefit patient groups currently underserved by existing TB diagnostics. Participants view the approach as a viable, acceptable, and likely sustainable option in low- and middle-income countries, though adaptations may be required to current health care processes for deployment. Trial registration: German Clinical Trials Register, DRKS00021003. URL: https://www.drks.de/drks_web/setLocale_EN.do.
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Affiliation(s)
- Yannis Herrmann
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Federica Lainati
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - María Del Mar Castro
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Chanda P Mwamba
- Centre for Infectious Disease Research in Zambia, Social & Behavioural Science Group, Lusaka, Zambia
| | - Moses Kumwenda
- Malawi-Liverpool-Wellcome Clinical Research Programme (MLW), Public Health Group, Blantyre, Malawi
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Tuberculosis Department, Lusaka, Zambia
| | - Tobias Broger
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Norbert Heinrich
- Division for Infectious Diseases, LMU Hospital, Munich, Germany
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Laura Olbrich
- Division for Infectious Diseases, LMU Hospital, Munich, Germany
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Elizabeth L Corbett
- London School of Hygiene and Tropical Medicine, Infectious and Tropical Diseases, London, United Kingdom
| | - Shannon A McMahon
- Heidelberg University Hospital, Heidelberg Institute of Global Health, Heidelberg, Germany
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Nora Engel
- Maastricht University, Department of Health, Ethics & Society, Research School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Claudia M Denkinger
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Partner Site Heidelberg University Hospital, Heidelberg, Germany
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Bigio J, van Gemert W, Kaiser B, Waning B, Pai M. Asia emerges as a hotbed of diagnostic innovations for tuberculosis. J Clin Tuberc Other Mycobact Dis 2021; 25:100267. [PMID: 34485710 PMCID: PMC8408512 DOI: 10.1016/j.jctube.2021.100267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jacob Bigio
- Research Institute of the McGill University Health Centre, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | | | | | | | - Madhukar Pai
- McGill International TB Centre, Montreal, Canada
- Dept of Epidemiology and Biostatistics, McGill University, Montreal, Canada
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21
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Mwaura M, Engel N. Constructing confidence: User perspectives on AlereLAM testing for tuberculosis. Int J Infect Dis 2021; 112:237-242. [PMID: 34525399 DOI: 10.1016/j.ijid.2021.09.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Diagnosing tuberculosis (TB) in people living with HIV (PLHIV) is challenging due to atypical clinical and radiological presentation and higher rates of sputum-negative or extrapulmonary disease. Urine LAM is a promising diagnostic biomarker to address these challenges. Yet, AlereLAM, a World Health Organization-recommended point-of-care (POC) test of this kind, remains underutilized. This study aimed to understand perspectives and experiences of those using AlereLAM. METHODS Fifteen semi-structured interviews were conducted with clinicians, nurses, program officers, laboratory staff, and patient advocates in Uganda, Kenya, and South Africa. Discussed topics included the approach to diagnosing TB, and experiences, perspectives, and country policy of AlereLAM testing. RESULTS The POC-friendly characteristics of AlereLAM require more work to be realized. Although limited by relatively low sensitivity and specificity, AlereLAM has important value for identifying TB in people with advanced HIV disease, especially when the environment enables constructing confidence in the test. The initial communication about the low performance by global agencies, restrictive eligibility criteria, reliance on CD4+ testing, and lack of advocacy and awareness were noted as reasons for its slow uptake. CONCLUSION The work of operationalizing diagnostics, including constructing confidence, is important to consider for policymakers, implementers, and funders when assessing acceptability, feasibility, and scale-up of a diagnostic.
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Affiliation(s)
- Muthoni Mwaura
- Department of Health, Ethics & Society; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Nora Engel
- Department of Health, Ethics & Society; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
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Matoga MM, Bisson GP, Gupta A, Miyahara S, Sun X, Fry C, Manabe YC, Kumwenda J, Cecilia K, Nyirenda M, Ngongondo M, Mbewe A, Lagat D, Wallis C, Mugerwa H, Hosseinipour MC. Urine Lipoarabinomannan Testing in Adults With Advanced Human Immunodeficiency Virus in a Trial of Empiric Tuberculosis Therapy. Clin Infect Dis 2021; 73:e870-e877. [PMID: 34398958 PMCID: PMC8366821 DOI: 10.1093/cid/ciab179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The urine lipoarabinomannan (LAM) antigen test is a tuberculosis (TB) diagnostic test with highest sensitivity in individuals with advanced human immunodeficiency virus (HIV). Its role in TB diagnostic algorithms for HIV-positive outpatients remains unclear. METHODS The AIDS Clinical Trials Group (ACTG) A5274 trial demonstrated that empiric TB therapy did not improve 24-week survival compared to isoniazid preventive therapy (IPT) in TB screen-negative HIV-positive adults initiating antiretroviral therapy with CD4 counts <50 cells/µL. Retrospective LAM testing was performed on stored urine obtained at baseline. We determined the proportion of LAM-positive participants and conducted modified intent-to-treat analysis excluding LAM-positive participants to determine the effect on 24-week survival, TB incidence, and time to TB using Kaplan-Meier method. RESULTS A5274 enrolled 850 participants; 53% were male and the median CD4 count was 18 (interquartile range, 9-32) cells/µL. Of the 850, 566 (67%) had LAM testing (283 per arm); 28 (5%) were positive (21 [7%] and 7 [2%] in the empiric and IPT arms, respectively). Of those LAM-positive, 1 participant in each arm died and 5 of 21 and 0 of 7 in empiric and IPT arms, respectively, developed TB. After excluding these 28 cases, there were 19 and 21 deaths in the empiric and IPT arms, respectively (P = .88). TB incidence remained higher (4.6% vs 2%, P = .04) and time to TB remained faster in the empiric arm (P = .04). CONCLUSIONS Among outpatients with advanced HIV who screened negative for TB by clinical symptoms, microscopy, and Xpert testing, LAM testing identified an additional 5% of individuals with TB. Positive LAM results did not change mortality or TB incidence.
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Affiliation(s)
| | - Gregory P Bisson
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amita Gupta
- Center for Clinical Global Health Education, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sachiko Miyahara
- Center for Biostatistics in AIDS Research, Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Xin Sun
- Center for Biostatistics in AIDS Research, Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Carrie Fry
- Frontier Science Foundation, Amherst, New York, USA
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Johnstone Kumwenda
- Malawi College of Medicine–Johns Hopkins University Research Project, Blantyre, Malawi
| | | | - Mulinda Nyirenda
- Malawi College of Medicine–Johns Hopkins University Research Project, Blantyre, Malawi
| | | | - Abineli Mbewe
- University of North Carolina Project, Lilongwe, Malawi
| | - David Lagat
- Moi University School of Medicine, Eldoret, Kenya
| | - Carole Wallis
- Bioanalytical Research Corporation and Lancet Laboratories, Johannesburg, South Africa
| | | | - Mina C Hosseinipour
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,USA
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Gupta-Wright A, Barnabas RV, Ingold H, Duneton P, Abubakar I. HIV self-testing: lessons learnt and priorities for adaptation in a shifting landscape. BMJ Glob Health 2021; 6:bmjgh-2020-004418. [PMID: 34275867 PMCID: PMC8287622 DOI: 10.1136/bmjgh-2020-004418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK .,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
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24
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Muyoyeta M, Kerkhoff AD, Chilukutu L, Moreau E, Schumacher SG, Ruhwald M. Diagnostic accuracy of a novel point-of-care urine lipoarabinomannan assay for the detection of tuberculosis among adult outpatients in Zambia: a prospective cross-sectional study. Eur Respir J 2021; 58:13993003.03999-2020. [PMID: 33926972 PMCID: PMC8631000 DOI: 10.1183/13993003.03999-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/05/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND A novel, rapid, point-of-care urine-based lipoarabinomannan assay (Fujifilm SILVAMP TB-LAM, "FujiLAM") has previously demonstrated substantially higher sensitivity for tuberculosis (TB) compared to the commercially-available Determine TB-LAM assay using bio-banked specimens. However, FujiLAM has not been prospectively evaluated using fresh urine specimens. Therefore, we determined the diagnostic accuracy of FujiLAM among HIV-positive and HIV-negative outpatients with presumptive TB in Zambia. METHODS Adult (≥18 years) presumptive TB patients presenting to two outpatient public health facilities in Lusaka, were included. All patients submitted sputa samples for smear-microscopy, Xpert Ultra and Mycobacterial culture and urine samples for the FujiLAM assay. Microbiologically-confirmed TB was defined by the detection of Mycobacterium tuberculosis in sputum using culture; this served as the reference standard to assess the diagnostic accuracy of FujiLAM. RESULTS 151 adults with paired sputum microbiologic tests and urine FujiLAM results were included; 45% were HIV-positive. Overall, 34/151 (23%) patients had culture-confirmed pulmonary TB. The overall sensitivity and specificity of FujiLAM was 77% (95% CI: 59-89) and 92% (95% CI: 86-96), respectively. FujiLAM's sensitivity among HIV-positive patients was 75% (95% CI: 43-95) compared to 75% (95% CI: 51-91) among HIV-negative patients. The sensitivity of FujiLAM in patients with smear-positive, confirmed pulmonary TB was 87% (95% CI: 60-98) compared to 68% (95%: 43-87) among patients with smear-negative, confirmed pulmonary TB. CONCLUSIONS FujiLAM demonstrated high sensitivity for the detection of TB among both HIV-positive and HIV-negative adults and also demonstrated good specificity despite the lack of systematic extra-pulmonary sampling to inform a comprehensive microbiological reference standard.
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Affiliation(s)
- Monde Muyoyeta
- Centre for Infectious Diseases research in Zambia, Lusaka, Zambia .,Contributed equally
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA.,Contributed equally
| | | | - Emmanuel Moreau
- Foundation for Innovative New diagnostics, Geneva, Switzerland
| | | | - Morten Ruhwald
- Foundation for Innovative New diagnostics, Geneva, Switzerland
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García JI, Allué-Guardia A, Tampi RP, Restrepo BI, Torrelles JB. New Developments and Insights in the Improvement of Mycobacterium tuberculosis Vaccines and Diagnostics Within the End TB Strategy. CURR EPIDEMIOL REP 2021; 8:33-45. [PMID: 33842192 PMCID: PMC8024105 DOI: 10.1007/s40471-021-00269-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW The alignment of sustainable development goals (SDGs) with the End Tuberculosis (TB) strategy provides an integrated roadmap to implement key approaches towards TB elimination. This review summarizes current social challenges for TB control, and yet, recent developments in TB diagnosis and vaccines in the context of the End TB strategy and SDGs to transform global health. RECENT FINDINGS Advances in non-sputum based TB biomarkers and whole genome sequencing technologies could revolutionize TB diagnostics. Moreover, synergistic novel technologies such as mRNA vaccination, nanovaccines and promising TB vaccine models are key promising developments for TB prevention and control. SUMMARY The End TB strategy depends on novel developments in point-of-care TB diagnostics and effective vaccines. However, despite outstanding technological developments in these fields, TB elimination will be unlikely achieved if TB social determinants are not fully addressed. Indeed, the End TB strategy and SDGs emphasize the importance of implementing sustainable universal health coverage and social protection.
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Affiliation(s)
- Juan Ignacio García
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, 8715 W. Military Dr, San Antonio, TX 78227 USA
| | - Anna Allué-Guardia
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, 8715 W. Military Dr, San Antonio, TX 78227 USA
| | - Radhika P. Tampi
- PhD Program in Health Policy, Harvard University, Cambridge, MA 02138 USA
| | - Blanca I. Restrepo
- University of Texas Health Science Center at Houston, School of Public Health, Brownsville, TX 78520 USA
- School of Medicine, South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Edinburg, TX 78539 USA
| | - Jordi B. Torrelles
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, 8715 W. Military Dr, San Antonio, TX 78227 USA
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Ignatius EH, Cohen KA, Bishai WR. Getting to the point in point-of-care diagnostics for tuberculosis. J Clin Invest 2021; 130:5671-5673. [PMID: 32986020 DOI: 10.1172/jci142497] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis (TB) continues to affect over 10 million people per year worldwide. Despite advances in diagnosis, smear microscopy insufficiently detects pulmonary disease, with test result reporting taking longer than a day. While urine assays to detect the lipopolysaccharide lipoarabinomannan (LAM), present in mycobacterial cell walls, can provide results within minutes, the currently available assay has low sensitivity and its application is limited to patients with HIV suspected of having TB. In this issue of the JCI, Broger and Nicol et al. investigated 3 rapid urine tests in 372 ambulatory HIV-negative individuals suspected of having TB in South Africa and Peru. FujiLAM emerged as a rapid test to confirm TB diagnosis in the HIV-seronegative population. This study shows that FujiLAM has considerable potential to reshape the TB diagnostics landscape, making diagnosis and treatment in one office visit a reality for TB.
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Affiliation(s)
- Elisa H Ignatius
- Division of Infectious Diseases.,Division of Clinical Pharmacology, and
| | - Keira A Cohen
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Huerga H, Mathabire Rucker SC, Bastard M, Mpunga J, Amoros Quiles I, Kabaghe C, Sannino L, Szumilin E. Urine Lipoarabinomannan Testing for All HIV Patients Hospitalized in Medical Wards Identifies a Large Proportion of Patients With Tuberculosis at Risk of Death. Open Forum Infect Dis 2020; 8:ofaa639. [PMID: 33575422 PMCID: PMC7863865 DOI: 10.1093/ofid/ofaa639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/18/2020] [Indexed: 11/14/2022] Open
Abstract
Background Diagnosing tuberculosis (TB), the leading cause of death in people with HIV, remains a challenge in resource-limited countries. We assessed TB diagnosis using a strategy that included systematic urine lipoarabinomannan (LAM) testing for all HIV patients hospitalized in medical wards and 6-month mortality according to LAM results. Methods This prospective, observational study included adult HIV patients hospitalized in the medical wards of a public district hospital in Malawi regardless of their TB symptoms or CD4 count. Each patient had a clinical examination, and Alere Determine TB-LAM, sputum microscopy, sputum GeneXpert MTB/RIF (Xpert), chest x-ray, and CD4 count were systematically requested. Results Among 387 inpatients, 54% had a CD4 <200 cells/µL, 64% had presumptive TB, and 90% had ≥1 TB symptom recorded in their medical file. LAM results were available for 99.0% of patients, microscopy for 62.8%, and Xpert for 60.7%. In total, 26.1% (100/383) had LAM-positive results, 48% (48/100) of which were grades 2-4. Any TB laboratory test result was positive in 30.8% (119/387). Among patients with no Xpert result, 28.5% (43/151) were LAM-positive. Cumulative 6-month mortality was 40.1% (151/377): 50.5% (49/97) in LAM-positives and 36.2% (100/276) in LAM-negatives (P = .013). In multivariable regression analyses, LAM-positive patients had a higher risk of mortality than LAM-negatives (adjusted odds ratio, 2.5; 95% CI, 1.1-5.8; P = .037). Conclusions In resource-limited hospital medical wards with high TB prevalence, a diagnostic strategy including systematic urine LAM testing for all HIV patients is an easily implementable strategy that identifies a large proportion of patients with TB at risk of death.
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Affiliation(s)
- Helena Huerga
- Epicentre, Paris, France
- Correspondence: Helena Huerga, MD, PhD, Epicentre, 14 - 34 Avenue Jean Jaurès, 75019 Paris, France ()
| | | | | | - James Mpunga
- National TB Program, Ministry of Health, Lilongwe, Malawi
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Abstract
Molecular tests for tuberculosis (TB) have the potential to help reach the three million people with TB who are undiagnosed or not reported each year and to improve the quality of care TB patients receive by providing accurate, quick results, including rapid drug-susceptibility testing. The World Health Organization (WHO) has recommended the use of molecular nucleic acid amplification tests (NAATs) tests for TB detection instead of smear microscopy, as they are able to detect TB more accurately, particularly in patients with paucibacillary disease and in people living with HIV. Importantly, some of these WHO-endorsed tests can detect mycobacterial gene mutations associated with anti-TB drug resistance, allowing clinicians to tailor effective TB treatment. Currently, a wide array of molecular tests for TB detection is being developed and evaluated, and while some tests are intended for reference laboratory use, others are being aimed at the point-of-care and peripheral health care settings. Notably, there is an emergence of molecular tests designed, manufactured, and rolled out in countries with high TB burden, of which some are explicitly aimed for near-patient placement. These developments should increase access to molecular TB testing for larger patient populations. With respect to drug susceptibility testing, NAATs and next-generation sequencing can provide results substantially faster than traditional phenotypic culture. Here, we review recent advances and developments in molecular tests for detecting TB as well as anti-TB drug resistance.
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Ndlovu Z, Burton R, Stewart R, Bygrave H, Roberts T, Fajardo E, Mataka A, Szumilin E, Kerschberger B, Van Cutsem G, Ellman T. Framework for the implementation of advanced HIV disease diagnostics in sub-Saharan Africa: programmatic perspectives. Lancet HIV 2020; 7:e514-e520. [PMID: 32473102 DOI: 10.1016/s2352-3018(20)30101-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 01/21/2023]
Abstract
Patients with advanced HIV disease have a high risk of mortality, mainly from tuberculosis and cryptococcal meningitis. The advanced HIV disease management package recommended by WHO, which includes diagnostics, therapeutics, and patient psychosocial support, is barely implemented in many different countries. Here, we present a framework for the implementation of advanced HIV disease diagnostics. Laboratory and point-of-care-based reflex testing, coupled with provider-initiated requested testing, for cryptococcal antigen and urinary Mycobacterium tuberculosis lipoarabinomannan antigen, should be done for all patients with CD4+ cell counts of 200 cells per μL or less. Implementation of the advanced HIV disease package should be encouraged within primary health-care facilities and task shifting of testing to lay cadres could facilitate access to rapid results. Implementation of differentiated antiretroviral therapy delivery models can allow clinicians enough time to focus on the management of patients with advanced HIV disease. Efficient up-referral and post-discharge systems, including the development of patient-centric advanced HIV disease literacy, are also crucial. Implementation of the advanced HIV disease package is feasible at all health-care levels, and it should be part of the core of the global response towards ending AIDS as a public health threat.
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Affiliation(s)
- Zibusiso Ndlovu
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa.
| | - Rosie Burton
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
| | | | - Helen Bygrave
- Médecins Sans Frontières, Access Campaign, Geneva, Switzerland
| | - Teri Roberts
- Médecins Sans Frontières, Access Campaign, Geneva, Switzerland
| | | | - Anafi Mataka
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
| | | | | | - Gilles Van Cutsem
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Tom Ellman
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
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Broger T, Nicol MP, Székely R, Bjerrum S, Sossen B, Schutz C, Opintan JA, Johansen IS, Mitarai S, Chikamatsu K, Kerkhoff AD, Macé A, Ongarello S, Meintjes G, Denkinger CM, Schumacher SG. Diagnostic accuracy of a novel tuberculosis point-of-care urine lipoarabinomannan assay for people living with HIV: A meta-analysis of individual in- and outpatient data. PLoS Med 2020; 17:e1003113. [PMID: 32357197 PMCID: PMC7194366 DOI: 10.1371/journal.pmed.1003113] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 04/09/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is the most common cause of death in people living with HIV (PLHIV), yet TB often goes undiagnosed since many patients are not able to produce a sputum specimen, and traditional diagnostics are costly or unavailable. A novel, rapid lateral flow assay, Fujifilm SILVAMP TB LAM (SILVAMP-LAM), detects the presence of TB lipoarabinomannan (LAM) in urine, and is substantially more sensitive for diagnosing TB in PLHIV than an earlier LAM assay (Alere Determine TB LAM lateral flow assay [LF-LAM]). Here, we present an individual participant data meta-analysis of the diagnostic accuracy of SILVAMP-LAM in adult PLHIV, including both published and unpublished data. METHODS AND FINDINGS Adult PLHIV (≥18 years) were assessed in 5 prospective cohort studies in South Africa (3 cohorts), Vietnam, and Ghana, carried out during 2012 to 2017. Of the 1,595 PLHIV who met eligibility criteria, the majority (61%) were inpatients, median age was 37 years (IQR 30-43), 43% had a CD4 count ≤ 100 cells/μl, and 35% were receiving antiretroviral therapy. Most participants (94%) had a positive WHO symptom screen for TB on enrollment, and 45% were diagnosed with microbiologically confirmed TB, using mycobacterial culture or Xpert MTB/RIF testing of sputum, urine, or blood. Previously published data from inpatients were combined with unpublished data from outpatients. Biobanked urine samples were tested, using blinded double reading, with SILVAMP-LAM and LF-LAM. Applying a microbiological reference standard for assessment of sensitivity, the overall sensitivity for TB detection was 70.7% (95% CI 59.0%-80.8%) for SILVAMP-LAM compared to 34.9% (95% CI 19.5%-50.9%) for LF-LAM. Using a composite reference standard (which included patients with both microbiologically confirmed as well as clinically diagnosed TB), SILVAMP-LAM sensitivity was 65.8% (95% CI 55.9%-74.6%), and that of LF-LAM 31.4% (95% CI 19.1%-43.7%). In patients with CD4 count ≤ 100 cells/μl, SILVAMP-LAM sensitivity was 87.1% (95% CI 79.3%-93.6%), compared to 56.0% (95% CI 43.9%-64.9%) for LF-LAM. In patients with CD4 count 101-200 cells/μl, SILVAMP-LAM sensitivity was 62.7% (95% CI 52.4%-71.9%), compared to 25.3% (95% CI 15.8%-34.9%) for LF-LAM. In those with CD4 count > 200 cells/μl, SILVAMP-LAM sensitivity was 43.9% (95% CI 34.3%-53.9%), compared to 10.9% (95% CI 5.2%-18.4%) for LF-LAM. Using a microbiological reference standard, the specificity of SILVAMP-LAM was 90.9% (95% CI 87.2%-93.7%), and that of LF-LAM 95.3% (95% CI 92.2%-97.7%). Limitations of this study include the use of biobanked, rather than fresh urine samples, and testing by skilled laboratory technicians in research laboratories, rather than at the point of care. CONCLUSIONS In this study, we found that SILVAMP-LAM identified a substantially higher proportion of TB patients in PLHIV than LF-LAM. The sensitivity of SILVAMP-LAM was highest in patients with CD4 count ≤ 100 cells/μl. Further work is needed to demonstrate accuracy when implemented as a point-of-care test.
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Affiliation(s)
| | - Mark P. Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Western Australia, Australia
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Cape Town, South Africa
| | | | - Stephanie Bjerrum
- Mycobacterial Research Centre of Southern Denmark, Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Unit of Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Bianca Sossen
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Charlotte Schutz
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Japheth A. Opintan
- Department of Medical Microbiology, School of Biomedical and Allied Sciences, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Isik S. Johansen
- Mycobacterial Research Centre of Southern Denmark, Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Unit of Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Satoshi Mitarai
- Department of Mycobacterium Reference and Research, Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Kinuyo Chikamatsu
- Department of Mycobacterium Reference and Research, Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, Department of Medicine, University of California, San Francisco, California, United States of America
| | | | | | - Graeme Meintjes
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Claudia M. Denkinger
- FIND, Geneva, Switzerland
- Division of Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
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