Living with HIV, Dying of TB
Intensified TB case finding among people
living with HIV
Adapted from presentation by Colleen Daniels
TB/HIV Advocacy
Stop TB Department, WHO
Outline of presentation
• What is intensified case finding?
• Global implementation of TB case finding
• Challenges
• Conclusions
Intensified Case Finding (ICF)
• Intensified TB case finding (ICF) is an activity,
recommended by the World Health Organization
(WHO), intended to detect possible TB cases as
early as possible among people living with HIV
– Screening for symptoms and signs of TB
• + TB treatment
• TB sputum smear
• - IPT
• ICF is the first step towards making a TB diagnosis.
Intensified Case Finding (ICF)
• TB control programs generally rely on
passive TB case finding
• People living with HIV are at much greater
risk of getting TB and if not treated soon
enough, dying from it
– often aggressive cases including hard-to-diagnose
smear-negative or extrapulmonary disease.
• ICF consists of using a simple questionnaire
looking for the signs and symptoms of TB.
Percentage of PLHIV screened for TB in
countries with 80% of the global burden, 2006.
2.00 1.83
1.80
1.60
1.40
1.20 1.07
0.96
1.00
0.77 0.78
0.80
0.60
0.40 0.31
0.20 0.05
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Proportion of PLHIV screened and diagnosed
with TB in selected countries, 2006
120,000
100,000
80,000
PLHIV screened for TB
60,000
PLHIV with TB after screening
40,000
29%
20,000
8% 20% 31%
0
South Africa Mozambique India Ethiopia
Country Screening Tools
National screening strategy: Kenya
Symptoms and signs Symptom and signs
Adults (any of) Children (any of)
1. Cough (of any duration)? 1. Cough: (of any duration)?
2. Blood stained sputum? 2. Blood stained sputum?
3. Night sweats >2 weeks 3. Night sweats >2 weeks
4. Fever ? 4. Fever? Of any duration?
5. Weight loss? 5. Weight loss?
6. Chest pain? 6. Chest pain?
7. Breathlessness? 7. Fast Breathing?
8. Fatigue? 8. Fatigue?
9. History of previous TB treatment? 9. History of previous TB treatment?
10. History of close contact with a 10. History of close contact with a
person confirmed to have TB? person confirmed to have TB?
11. Swellings in the neck, armpits or 11. Swellings in the neck, armpits or
elsewhere? elsewhere?
12: Diarrhea for more than two weeks? 12: Diarrhea for more than 2 weeks?
13. Failure to thrive?
National screening strategy: Malawi
Any of the following
• Cough more than 3wks
• Weight loss
• Fever or night sweats
• Fatigue/tiredness
• Loss of appetite
• Lymph node
enlargement
Screening tools in countries
• Screening tools vary from country to country
• More and more non-specific constitutional
symptoms and signs included in tools
• Children are not addressed
• Presence of nationally recommended screening
tool does not always guarantee implementation
Challenge: implementation issues
• Standardised screening tool needed?
• Screening tool that can rule out active TB disease
is needed and how best to link it with IPT?
• Who administers the standard tool and where?
• How often should it be administered?
• Monitoring and evaluation- how should it be
recorded and reported?
Review of some published evidence
of TB screening strategies
Kimerling, et.al – Cambodia,2002
IJTLD 2002; 6:988–994
Population 441 HIV+ in home-based care
Gold stn. Single sputum culture
# with TB 41 (9%) with culture-confirmed TB
Cough Cough >3 weeks 65% sensitive, 33% specific
Algorithm Any 1 of: - cough>3 wks
- hemoptysis
- weight loss
Sensitivity= 95%
- fever Specificity= 10%
- night sweats
- weakness
No information on role of CXR
Day, et. al. – South Africa, 2006
IJTLD 2006: 10:523-529
Population 899 HIV-infected miners being evaluated for IPT
Gold Stn. Culture positive or clinical improvement
# with TB 44 (5%) patients met definition for TB, 35 culture +
Cough Cough >3 weeks 14% sensitive, 88% specific
Algorithm • Any 1 of - night sweats
- new or worsening cough Sensitivity= 91%
- weight loss >5% Specificity= 59%
- abnormal CXR.
• Combination of - night sweats
- cough
- reported weight loss Sensitivity= 59%
Specificity= 76%
CXR increased the sensitivity of the screening
Demissie, et.al. – Ethiopia
World Lung Health Conference 2007 Abstract S11
Setting Addis Ababa, Ethiopia – community hospital
Study pop. 438 newly diagnosed HIV+
Gold Stn. Concentrated sputum smear and culture
# with TB 32 (7%) with culture-confirmed TB
Cough Cough> 2 wks is 44% sensitive, 76% specific
Algorithm Cough or fever – 75% sensitivity, 57% specificity
CXR improved sensitivity to 91% (at a cost of
specificity)
Some Notes and Observations from
available evidence
• Sesitivity: Ability of the test to accurately diagnose the presence of
disease.
• Specificity: Ability of the test to accurately identify all people without
the condition
These are both measures of accuracy of a screening tool to identify a
person with TB, the higher the Sensitivity and Specificity the more
accurate the tool.
• The accuracy of screening are generally inconsistent and dependent
what types of screening questions are asked. Eg: the more the
symptoms the greater the chances of detecting anyone with TB, but
also the greater the chances of wrongly suspecting that people have
TB when they don’t.
• Chronic cough more than 2 or 3 wks alone looks insensitive predictor
of TB in PLHIV
• Role of CXR is not clear and inconsistent
Living with HIV, Dying of TB
Conclusions
• People with HIV have the right to ask for TB screening
and diagnosis.
• Check your country's progress in implementing the 12
collaborative activities and engage with the NTP and
NAP to call for scale up (Global TB Report)
Conclusions
• Mobilization by civil society urgently needed to scale
up ICF.
– Community driven to create demand
– Educate – increase literacy in communities and at
health care facilities
– Work with joint TB/HIV national mechanisms to
rapidly scale up
– Engage in processes such as Global Fund CCMs
– Demand creation
– Myth busting - ensure that arguments about challenges to
implementation are not a barrier (HIV experience) - Just do it!
Conclusions
• Massive research efforts to develop the best
and feasible screening tool are urgently
needed
– "TB dipstick test"- simple and rapid tool is
crucial
• Call for investment and increase in laboratory
capacity and call for adequate referral
systems
• Recording and reporting