Tuberculosis Case Finding in HIV-Infected Pregnant Women in Kenya Reveals Poor Performance of Symptom Screening and Rapid Diagnostic Tests.
BACKGROUND
Tuberculosis (TB) during pregnancy in HIV-infected women is associated with poor maternal and infant outcomes. There are limited data on TB prevalence, optimal TB screening, and performance of rapid diagnostics in pregnant HIV-infected women.


METHODS
We conducted a cross-sectional study among HIV-infected pregnant women seeking antenatal care in western Kenya. After a standardized questionnaire, sputum smear microscopy for acid-fast bacilli, mycobacterial liquid culture, GeneXpert MTB/RIF (Xpert), urine lipoarabinomannan, and tuberculin skin testing were performed. We determined prevalence and correlates of culture-confirmed pulmonary TB, and compared diagnostic performance of World Health Organization (WHO) symptom screening and rapid diagnostic tests to sputum culture.


RESULTS
Between July 2013 and July 2014, we enrolled 306 women. Among 288 women with a valid sputum culture result, 54% were on antiretroviral treatment, median CD4 cell count was 437 cell per cubic millimeter (IQR 342-565), and prevalence of culture-confirmed pulmonary TB was 2.4% (confidence interval: 1.0% to 4.9%). Cough >2 weeks (P = 0.04) and positive tuberculin skin testing (≥ 5 mm, P = 0.03) were associated with pulmonary TB. Women with TB were 23-fold (95% confidence interval: 4.4 to 116.6) more likely to report a household member with TB symptoms (P = 0.002). WHO symptom screen (43%), acid-fast bacilli smear (0%), Xpert (43%), and lipoarabinomannan (0%) had low sensitivity but high specificity (81%, 99%, 99%, and 95%, respectively) for pulmonary TB.


CONCLUSIONS
HIV-infected pregnant women had appreciable prevalence of pulmonary TB despite modest immunosuppression. Current TB screening and diagnostic tools perform poorly in pregnant HIV-infected women. Adapted TB screening tools that include household member TB symptoms may be useful in this population.
Departments of *Medicine; †Pediatrics, University of Washington, Seattle, WA; ‡Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA; Departments of §Reproductive Health; ‖Research and Programs, Kenyatta National Hospital, Nairobi, Kenya; Departments of ¶Biostatistics; #Epidemiology; **Global Health, University of Washington, Seattle, WA; and ††Firland Northwest Tuberculosis Center, University of Washington, Seattle, WA.
Sylvia M
SM
LaCourse
Lisa M
LM
Cranmer
Daniel
D
Matemo
John
J
Kinuthia
Barbra A
BA
Richardson
Grace
G
John-Stewart
David J
DJ
Horne
D000328:Adult; D018791:CD4 Lymphocyte Count; D003430:Cross-Sectional Studies; D003955:Diagnostic Tests, Routine; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008403:Mass Screening; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis* / Q000453:epidemiology; D015995:Prevalence; D013183:Sputum / Q000382:microbiology; D011795:Surveys and Questionnaires; D014374:Tuberculin Test; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology; D055815:Young Adult