Tuberculosis among adults starting antiretroviral therapy in South Africa: the need for routine case finding.
OBJECTIVE
To investigate the prevalence of and evaluate screening modalities for undiagnosed tuberculosis (TB) in antiretroviral therapy (ART) eligible adults in South Africa.


METHODS
Individuals were screened for TB using symptoms, chest radiograph (CXR) and two sputum specimens  for microscopy and culture, and were then followed for <6 months to determine TB diagnoses.


RESULTS
Among 361 participants (67% female, median age 38 years, median CD4 count 120 cells/mm(3)), 64 (18%) were sputum culture-positive; 114 (32%) fulfilled any TB case definition  (culture- and/or smear-positive, or improvement on specific treatment). Symptom screening comprising any of cough, appetite loss or night sweats > 2 weeks had a sensitivity and specificity of respectively 74.5% and 50.8%. Sensitivity was increased by CXR (to 96.1%), but not by smear microscopy.  The World Health Organization symptom screen had a sensitivity and specificity of respectively 96.1% and 5.2% in our study population; the addition of CXR increased sensitivity to 100%. Median time to TB treatment was 8 days for diagnoses based on CXR (n = 72) vs. 37 days for diagnoses  based only on sputum culture (n = 14).


CONCLUSIONS
The very high prevalence of undiagnosed TB among patients presenting for ART mandates their routine investigation. CXR improved sensitivity substantially, allowed rapid treatment initiation and should be routine, where available,  pending better point-of-care diagnostics.
Aurum Institute, Johannesburg, South Africa. yhanifa@hotmail.com
Y
Y
Hanifa
K L
KL
Fielding
S
S
Charalambous
E
E
Variava
B
B
Luke
G J
GJ
Churchyard
A D
AD
Grant
D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000627:therapeutic use; D060085:Coinfection; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D016015:Logistic Models; D008297:Male; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D016017:Odds Ratio; D010044:Outpatient Clinics, Hospital; D019095:Point-of-Care Systems; D011237:Predictive Value of Tests; D015995:Prevalence; D011446:Prospective Studies; D017150:Public Sector; D013902:Radiography, Thoracic; D012680:Sensitivity and Specificity; D013019:South Africa / Q000453:epidemiology; D013183:Sputum / Q000382:microbiology; D013997:Time Factors; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology
D044966:Anti-Retroviral Agents; D000995:Antitubercular Agents