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Hanifa Y, Fielding KL, Chihota VN, Adonis L, Charalambous S, Foster N, Karstaedt A, McCarthy K, Nicol MP, Ndlovu NT, Sinanovic E, Sahid F, Stevens W, Vassall A, Churchyard GJ, Grant AD. The utility of repeat Xpert MTB/RIF testing to diagnose tuberculosis in HIV-positive adults with initial negative result. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.12815.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Amongst HIV-positive adults in South Africa with initial negative Xpert results, we compared the yield from repeating Xpert MTB/RIF (“Xpert”) on sputum to guideline-recommended investigation for tuberculosis (TB). Methods: A systematic sample of adults attending for HIV care were enrolled in a cohort exploring TB investigation pathways. This substudy was restricted to those at highest risk of TB (CD4<200 cells/mm3 or unknown) who had a negative initial Xpert result. At attendance for the Xpert result, a repeat sputum sample was stored, and further investigations facilitated per national guidelines. Participants were reviewed monthly, with reinvestigation if indicated, for at least three months, when sputum and blood were cultured for mycobacteria, and the stored sputum tested using Xpert. We defined TB as “confirmed” if Xpert, line probe assay or Mycobacterium tuberculosis culture within six months of enrolment were positive, and “clinical” if TB treatment was started without microbiological confirmation. Results: Amongst 227 participants with an initial negative Xpert result (63% female, median age 37 years, median CD4 count 100 cells/mm3), 28 (12%) participants had TB diagnosed during study follow-up (16 confirmed, 12 clinical); stored sputum tested positive on Xpert in 5/227 (2%). Amongst 27 participants who started TB treatment, the basis was bacteriological confirmation 11/27 (41%); compatible imaging 11/27 (41%); compatible symptoms 2/27 (7%); and unknown 3/27 (11%). Conclusions: Amongst HIV-positive individuals at high risk of active TB with a negative Xpert result, further investigation using appropriate diagnostic modalities is more likely to lead to TB treatment than immediately repeating sputum for Xpert. TB diagnostic tests with improved sensitivity are needed.
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Hanifa Y, Fielding KL, Chihota VN, Adonis L, Charalambous S, Foster N, Karstaedt A, McCarthy K, Nicol MP, Ndlovu NT, Sinanovic E, Sahid F, Stevens W, Vassall A, Churchyard GJ, Grant AD. The utility of repeat Xpert MTB/RIF testing to diagnose tuberculosis in HIV-positive adults with initial negative result. Gates Open Res 2022; 2:22. [PMID: 37700854 PMCID: PMC10495190 DOI: 10.12688/gatesopenres.12815.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 09/14/2023] Open
Abstract
Background: Amongst HIV-positive adults in South Africa with initial negative Xpert results, we compared the yield from repeating Xpert MTB/RIF ("Xpert") on sputum to guideline-recommended investigation for tuberculosis (TB). Methods: A systematic sample of adults attending for HIV care were enrolled in a cohort exploring TB investigation pathways. This substudy was restricted to those at highest risk of TB (CD4<200 cells/mm 3 or unknown) who had a negative initial Xpert result. At attendance for the Xpert result, a repeat sputum sample was stored, and further investigations facilitated per national guidelines. Participants were reviewed monthly, with reinvestigation if indicated, for at least three months, when sputum and blood were cultured for mycobacteria, and the stored sputum tested using Xpert. We defined TB as "confirmed" if Xpert, line probe assay or Mycobacterium tuberculosis culture within six months of enrolment were positive, and "clinical" if TB treatment was started without microbiological confirmation. Results: Amongst 227 participants with an initial negative Xpert result (63% female, median age 37 years, median CD4 count 100 cells/mm 3), 28 (12%) participants had TB diagnosed during study follow-up (16 confirmed, 12 clinical); stored sputum tested positive on Xpert in 5/227 (2%). Amongst 27 participants who started TB treatment, the basis was bacteriological confirmation 11/27 (41%); compatible imaging 11/27 (41%); compatible symptoms 2/27 (7%); and unknown 3/27 (11%). Conclusions: Amongst HIV-positive individuals at high risk of active TB with a negative Xpert result, further investigation using appropriate diagnostic modalities is more likely to lead to TB treatment than immediately repeating sputum for Xpert. TB diagnostic tests with improved sensitivity are needed.
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Affiliation(s)
- Yasmeen Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Violet N. Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Alan Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Mark P. Nicol
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | | | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Faieza Sahid
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy Stevens
- National Health Laboratory Service, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anna Vassall
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Gavin J. Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Advancing Care and Treatment for TB/HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Johannesburg, South Africa
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Hanifa Y, Toro Silva S, Karstaedt A, Sahid F, Charalambous S, Chihota VN, Churchyard GJ, von Gottberg A, McCarthy K, Nicol MP, Ndlovu NT, Stevens W, Fielding KL, Grant AD. What causes symptoms suggestive of tuberculosis in HIV-positive people with negative initial investigations? Int J Tuberc Lung Dis 2019; 23:157-165. [PMID: 30678747 PMCID: PMC6394279 DOI: 10.5588/ijtld.18.0251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE: To identify the causes of symptoms suggestive of tuberculosis (TB) among people living with the human immunodeficiency virus (PLHIV) in South Africa. METHODS: A consecutive sample of HIV clinic attendees with symptoms suggestive of TB (⩾1 of cough, weight loss, fever or night sweats) at enrolment and at 3 months, and negative initial TB investigations, were systematically evaluated with standard protocols and diagnoses assigned using standard criteria. TB was ‘confirmed’ if Mycobacterium tuberculosis was identified within 6 months of enrolment, and ‘clinical’ if treatment started without microbiological confirmation. RESULTS: Among 103 participants, 50/103 were preantiretroviral therapy (ART) and 53/103 were on ART; respectively 68% vs. 79% were female; the median age was 35 vs. 45 years; the median CD4 count was 311 vs. 508 cells/mm3. Seventy-two (70%) had ⩾5% measured weight loss and 50 (49%) had cough. The most common final diagnoses were weight loss due to severe food insecurity (n = 20, 19%), TB (n = 14, 14%: confirmed n = 7; clinical n = 7), other respiratory tract infection (n = 14, 14%) and post-TB lung disease (n = 9, 9%). The basis for TB diagnosis was imaging (n = 7), bacteriological confirmation from sputum (n = 4), histology, lumbar puncture and other (n = 1 each). CONCLUSION: PLHIV with persistent TB symptoms require further evaluation for TB using all available modalities, and for food insecurity in those with weight loss.
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Affiliation(s)
- Y Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - S Toro Silva
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, University of the Witwatersrand, Johannesburg
| | - F Sahid
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, University of the Witwatersrand, Johannesburg
| | - S Charalambous
- The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - V N Chihota
- The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - G J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK, The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Advancing Care and Treatment for TB-HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Tygerberg
| | - A von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | | | - M P Nicol
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, National Health Laboratory Service, Johannesburg
| | | | - W Stevens
- National Health Laboratory Service, Johannesburg, Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - K L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Hanifa Y, Fielding KL, Chihota VN, Adonis L, Charalambous S, Foster N, Karstaedt A, McCarthy K, Nicol MP, Ndlovu NT, Sinanovic E, Sahid F, Stevens W, Vassall A, Churchyard GJ, Grant AD. A clinical scoring system to prioritise investigation for tuberculosis among adults attending HIV clinics in South Africa. PLoS One 2017; 12:e0181519. [PMID: 28771504 PMCID: PMC5542442 DOI: 10.1371/journal.pone.0181519] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 06/21/2017] [Indexed: 12/23/2022] Open
Abstract
Background The World Health Organization (WHO) recommendation for regular tuberculosis (TB) screening of HIV-positive individuals with Xpert MTB/RIF as the first diagnostic test has major resource implications. Objective To develop a diagnostic prediction model for TB, for symptomatic adults attending for routine HIV care, to prioritise TB investigation. Design Cohort study exploring a TB testing algorithm. Setting HIV clinics, South Africa. Participants Representative sample of adult HIV clinic attendees; data from participants reporting ≥1 symptom on the WHO screening tool were split 50:50 to derive, then internally validate, a prediction model. Outcome TB, defined as “confirmed” if Xpert MTB/RIF, line probe assay or M. tuberculosis culture were positive; and “clinical” if TB treatment started without microbiological confirmation, within six months of enrolment. Results Overall, 79/2602 (3.0%) participants on ART fulfilled TB case definitions, compared to 65/906 (7.2%) pre-ART. Among 1133/3508 (32.3%) participants screening positive on the WHO tool, 1048 met inclusion criteria for this analysis: 52/515 (10.1%) in the derivation and 58/533 (10.9%) in the validation dataset had TB. Our final model comprised ART status (on ART > 3 months vs. pre-ART or ART < 3 months); body mass index (continuous); CD4 (continuous); number of WHO symptoms (1 vs. >1 symptom). We converted this to a clinical score, using clinically-relevant CD4 and BMI categories. A cut-off score of ≥3 identified those with TB with sensitivity and specificity of 91.8% and 34.3% respectively. If investigation was prioritised for individuals with score of ≥3, 68% (717/1048) symptomatic individuals would be tested, among whom the prevalence of TB would be 14.1% (101/717); 32% (331/1048) of tests would be avoided, but 3% (9/331) with TB would be missed amongst those not tested. Conclusion Our clinical score may help prioritise TB investigation among symptomatic individuals.
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Affiliation(s)
- Yasmeen Hanifa
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Violet N Chihota
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola Foster
- Health Economics Unit, School of public health and family medicine, University of Cape Town, Cape Town, South Africa
| | - Alan Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
| | | | - Mark P Nicol
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service, Johannesburg, South Africa
| | | | - Edina Sinanovic
- Health Economics Unit, School of public health and family medicine, University of Cape Town, Cape Town, South Africa
| | - Faieza Sahid
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy Stevens
- National Health Laboratory Service, Johannesburg, South Africa.,Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anna Vassall
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Gavin J Churchyard
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Advancing Treatment and Care for TB/HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Johannesburg, South Africa
| | - Alison D Grant
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Nursing and Public Health, Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
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Hanifa Y, Fielding KL, Chihota VN, Adonis L, Charalambous S, Karstaedt A, McCarthy K, Nicol MP, Ndlovu NT, Sahid F, Churchyard GJ, Grant AD. Diagnostic Accuracy of Lateral Flow Urine LAM Assay for TB Screening of Adults with Advanced Immunosuppression Attending Routine HIV Care in South Africa. PLoS One 2016; 11:e0156866. [PMID: 27271432 PMCID: PMC4896615 DOI: 10.1371/journal.pone.0156866] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 05/19/2016] [Indexed: 12/03/2022] Open
Abstract
Background We assessed the diagnostic accuracy of Determine TB-LAM (LF-LAM) to screen for tuberculosis among ambulatory adults established in HIV care in South Africa. Methods A systematic sample of adults attending for HIV care, regardless of symptomatology, were enrolled in the XPHACTOR study, which tested a novel algorithm for prioritising investigation with Xpert MTB/RIF. In this substudy, restricted to participants with enrolment CD4<200x106/l, urine was stored at enrolment for later testing with LF-LAM. Sputum was sent for immediate Xpert MTB/RIF if any of: current cough, fever ≥3 weeks, body mass index (BMI)<18.5kg/m2, CD4<100x106/l (or <200x106/l if pre-ART), weight loss ≥10% or strong clinical suspicion were present; otherwise, sputum was stored for Xpert testing at study completion. Participants were reviewed monthly, with reinvestigation if indicated, to 3 months, when sputum and blood were taken for mycobacterial culture. We defined tuberculosis as “confirmed” if Xpert, line probe assay or culture for M. tuberculosis within six months of enrolment were positive, and “clinical” if tuberculosis treatment started without microbiological confirmation. Results Amongst 424 participants, 61% were female and 57% were taking ART (median duration 22 months); median age, CD4 and BMI were 39 years, 111x106/l, and 23 kg/m2. 56/424 (13%) participants had tuberculosis (40 confirmed, 16 clinical). 24/424 (5.7%) vs. 8/424 (1.9%) were LAM-positive using grade 1 vs. grade 2 cut-off. Using grade 1 cut-off, sensitivity for confirmed TB (all clinical TB excluded) was 12.5% (95% CI 4.2%, 26.8%) and in CD4<100x106/l vs. CD4 ≥100x106/l was 16.7% (95% CI 4.7%, 37.4%) vs. 6.3% (95% CI 0.2%, 30.2%). Specificity was >95% irrespective of diagnostic reference standard, CD4 stratum, or whether grade 1 or grade 2 cut-off was used. Conclusion Sensitivity of LF-LAM is too low to recommend as part of intensified case finding in ambulatory patients established in HIV care.
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Affiliation(s)
- Yasmeen Hanifa
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | | | - Violet N. Chihota
- Aurum Institute, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Salome Charalambous
- Aurum Institute, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Alan Karstaedt
- University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | | | - Mark P. Nicol
- National Health Laboratory Service, Johannesburg, South Africa
- University of Cape Town, Cape Town, South Africa
| | | | - Faieza Sahid
- University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Gavin J. Churchyard
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Aurum Institute, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
- Advancing Care and Treatment (ACT) for TB/HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Cape Town, South Africa
| | - Alison D. Grant
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- University of the Witwatersrand, Johannesburg, South Africa
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